Basic Information
| Provider Information | |||||||||
| NPI: | 1992043772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZDROIK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | CSAC | ||||||||
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| 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: | 01/29/2013 | ||||||||
| LastUpdateDate: | 01/29/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 11450-132 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 5314-120 | WI | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 5314-120 | 01 | WI | LICENSE-SOCIAL WORKER | OTHER | 11450-132 | 01 | WI | LICENSE-CSAC | OTHER |