Provider Demographics
NPI:1770776429
Name:CONWAY, ELAINE THERESE (MS, LPC)
Entity type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:THERESE
Last Name:CONWAY
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:CONWAY
Other - Last Name:MELLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3900 W BROWN DEER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1220
Mailing Address - Country:US
Mailing Address - Phone:414-540-2170
Mailing Address - Fax:414-540-2171
Practice Address - Street 1:934 S CLAY ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3419
Practice Address - Country:US
Practice Address - Phone:920-819-6570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3537-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40953300Medicaid