Provider Demographics
NPI:1356921548
Name:FENNELL, GLORIA LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:LYNN
Last Name:FENNELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:LA POINTE
Mailing Address - State:WI
Mailing Address - Zip Code:54850-0162
Mailing Address - Country:US
Mailing Address - Phone:715-456-9369
Mailing Address - Fax:
Practice Address - Street 1:1099 S SHORE RD
Practice Address - Street 2:
Practice Address - City:LA POINTE
Practice Address - State:WI
Practice Address - Zip Code:54850-4516
Practice Address - Country:US
Practice Address - Phone:715-456-9369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1203-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty