Provider Demographics
NPI:1497016752
Name:GROSSKURTH, ANDREA LINETTE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LINETTE
Last Name:GROSSKURTH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:LINETTE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6809 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7335
Mailing Address - Country:US
Mailing Address - Phone:262-652-5522
Mailing Address - Fax:262-652-7228
Practice Address - Street 1:6809 122ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7335
Practice Address - Country:US
Practice Address - Phone:262-652-5522
Practice Address - Fax:262-652-7228
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1497016752Medicaid