Basic Information
| Provider Information | |||||||||
| NPI: | 1104980119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENNESSY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | MARGARET | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N OAK AVE | ||||||||
| Address2: | |||||||||
| City: | MARSHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544495703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153875511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 N OAK AVE | ||||||||
| Address2: | |||||||||
| City: | MARSHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544495703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153875511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 33238 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 33238 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | 56027 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.