Provider Demographics
NPI:1053449173
Name:NORTHWAY, ROGER PATRICK (MS LCSW)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:PATRICK
Last Name:NORTHWAY
Suffix:
Gender:M
Credentials:MS LCSW
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Other - First Name:
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Mailing Address - Street 1:13105 W BLUEMOUND RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-8046
Mailing Address - Country:US
Mailing Address - Phone:262-641-9790
Mailing Address - Fax:262-641-9791
Practice Address - Street 1:13105 W BLUEMOUND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-8046
Practice Address - Country:US
Practice Address - Phone:262-641-9790
Practice Address - Fax:262-641-9791
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI477125101YP2500X
WI26611231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39197200Medicaid