Provider Demographics
NPI:1366895989
Name:NEWBAUER, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NEWBAUER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6395 BLOSSOM CT
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-1367
Mailing Address - Country:US
Mailing Address - Phone:414-704-2823
Mailing Address - Fax:
Practice Address - Street 1:6395 BLOSSOM CT
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-1367
Practice Address - Country:US
Practice Address - Phone:414-704-2823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8510-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical