Provider Demographics
NPI:1902968308
Name:WESCHE, GRETCHEN M (MA LICSW)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:M
Last Name:WESCHE
Suffix:
Gender:F
Credentials:MA LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1884 CROSS POINTE WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5010
Mailing Address - Country:US
Mailing Address - Phone:763-360-8023
Mailing Address - Fax:
Practice Address - Street 1:1884 CROSS POINTE WAY
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5010
Practice Address - Country:US
Practice Address - Phone:763-360-8023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8518104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN839057600Medicaid