Provider Demographics
NPI:1740499383
Name:DESMOND, MARY CATHERINE (LICSW, LPC, CSAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:DESMOND
Suffix:
Gender:F
Credentials:LICSW, LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N8301 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-9151
Mailing Address - Country:US
Mailing Address - Phone:920-261-3309
Mailing Address - Fax:
Practice Address - Street 1:N8301 COUNTY ROAD A
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-9151
Practice Address - Country:US
Practice Address - Phone:920-261-3309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2006-132101YA0400X
WI1524-125101YP2500X
WI3358-1231041C0700X
WI37015-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered163W00000XNursing Service ProvidersRegistered Nurse