Basic Information
Provider Information
NPI: 1033556337
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MULRY
FirstName: GREGORY
MiddleName: W
NamePrefix:  
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1225 W MITCHELL ST
Address2: 223
City: MILWAUKEE
State: WI
PostalCode: 532043383
CountryCode: US
TelephoneNumber: 4143834455
FaxNumber: 4147278730
Practice Location
Address1: 1225 W MITCHELL ST
Address2: 223
City: MILWAUKEE
State: WI
PostalCode: 532043383
CountryCode: US
TelephoneNumber: 4143834455
FaxNumber: 4147278730
Other Information
ProviderEnumerationDate: 05/28/2013
LastUpdateDate: 05/28/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X715-123WIY Behavioral Health & Social Service ProvidersSocial WorkerClinical

ID Information
IDTypeStateIssuerDescription
715-12301WIWI STATE LICENSEOTHER


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