Basic Information
| Provider Information | |||||||||
| NPI: | 1457496523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCARTY | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOMUTH | ||||||||
| OtherFirstName: | MAUREEN | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 206 | ||||||||
| Address2: | 122 W SOUTH ST | ||||||||
| City: | VIROQUA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546650209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086372511 | ||||||||
| FaxNumber: | 6086377921 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 NO PRAIRIE ST | ||||||||
| Address2: | |||||||||
| City: | PRAIRIE DU CHIEN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 538210525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083262384 | ||||||||
| FaxNumber: | 6086377921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2404123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39299300 | 05 | WI | MEDICAID |