Basic Information
| Provider Information | |||||||||
| NPI: | 1235425885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PASSAGE | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LCSW, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1143 WARWICK WAY UNIT A | ||||||||
| Address2: | |||||||||
| City: | RACINE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534065661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627891191 | ||||||||
| FaxNumber: | 2625834014 | ||||||||
| Practice Location | |||||||||
| Address1: | 1143 WARWICK WAY UNIT A | ||||||||
| Address2: | |||||||||
| City: | RACINE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534065661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627891191 | ||||||||
| FaxNumber: | 2625834014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2011 | ||||||||
| LastUpdateDate: | 02/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3819-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1235425885 | 05 | WI | MEDICAID |