Provider Demographics
NPI:1720497118
Name:VANDEN WYMELENBERG, MARY JO (LCSW,CSAC)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:VANDEN WYMELENBERG
Suffix:
Gender:F
Credentials:LCSW,CSAC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:J
Other - Last Name:BRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 22040
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2040
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:301 E SAINT JOSEPH ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2241
Practice Address - Country:US
Practice Address - Phone:920-433-6073
Practice Address - Fax:920-431-0333
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15798-132101YA0400X
WI9381-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)