Basic Information
| Provider Information | |||||||||
| NPI: | 1043755440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MURPHY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | CAPSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 KESSEL CT | ||||||||
| Address2: | STE 105 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537116227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082802700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 49 KESSEL CT | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537116275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082802700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2016 | ||||||||
| LastUpdateDate: | 03/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 130409-121 | WI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 130409-121 | 01 | WI | WISCONSIN STATE SOCIAL WORK CAPSW LICENSE | OTHER |