Provider Demographics
NPI:1861524365
Name:MARY DETERMAN MSW, LLC
Entity type:Organization
Organization Name:MARY DETERMAN MSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARYELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROZGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-431-6400
Mailing Address - Street 1:5757 W OKLAHOMA AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53219-4303
Mailing Address - Country:US
Mailing Address - Phone:414-431-6400
Mailing Address - Fax:414-431-6401
Practice Address - Street 1:5757 W OKLAHOMA AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53219-4303
Practice Address - Country:US
Practice Address - Phone:414-431-6400
Practice Address - Fax:414-431-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42235600Medicaid
WI44680Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER