Provider Demographics
NPI:1457870644
Name:WIATROWSKI, MARY DIANE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DIANE
Last Name:WIATROWSKI
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-5728
Mailing Address - Country:US
Mailing Address - Phone:920-410-7156
Mailing Address - Fax:
Practice Address - Street 1:404 N MAIN ST STE 612
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-4953
Practice Address - Country:US
Practice Address - Phone:920-385-1420
Practice Address - Fax:866-327-3295
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4176-123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker