Active NPI
Mary Jean Gonwa, LCSW
- Social Worker
- West Bend, WI
National Provider Identifier
1477661767
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Social Worker
- License
- 796
- Practice address
- 279 S 17TH Ave
Suite 10
West Bend, WI 53095-3001 - Phone
- (262) 306-9317
- NPI assigned
- Aug 27, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Social Worker | 104100000X | 796 | WI | Primary |
Addresses
Primary practice location
279 S 17TH Ave
Suite 10
West Bend, WI 53095-3001
Mailing address
111 E Washington St
Suite 200
West Bend, WI 53095-2571
Phone (262) 338-2717
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 39708200 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 796 | WI | MD | Podiatrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156636800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1475625600000",
"number": "1477661767",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "111 E WASHINGTON ST",
"address_2": "SUITE 200",
"city": "WEST BEND",
"state": "WI",
"postal_code": "530952571",
"telephone_number": "262-338-2717",
"fax_number": "262-338-9767"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "279 S 17TH AVE",
"address_2": "SUITE 10",
"city": "WEST BEND",
"state": "WI",
"postal_code": "530953001",
"telephone_number": "262-306-9317"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GONWA",
"first_name": "MARY",
"middle_name": "JEAN",
"name_prefix": "Mrs.",
"credential": "LCSW",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-08-27",
"last_updated": "2016-10-05",
"status": "A"
},
"taxonomies": [
{
"code": "104100000X",
"taxonomy_group": "",
"desc": "Social Worker",
"state": "WI",
"license": "796",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "39708200",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in West Bend, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 5, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.