Basic Information
| Provider Information | |||||||||
| NPI: | 1245223742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORANSON | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3630 N HICKORY LN | ||||||||
| Address2: | ROGERS MEMORIAL HOSPITAL | ||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626461338 | ||||||||
| FaxNumber: | 2626467067 | ||||||||
| Practice Location | |||||||||
| Address1: | 11101 W LINCOLN AVE | ||||||||
| Address2: | ROGERS MEMORIAL HOSPITAL | ||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532271133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142034480 | ||||||||
| FaxNumber: | 4143283737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1624 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 39131400 | 05 | WI | MEDICAID |