Provider Demographics
NPI:1447346465
Name:BASHAM, MARY E (LMFT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:BASHAM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:C
Other - Last Name:GERSTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2350 WOODMOOR LN
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4259
Mailing Address - Country:US
Mailing Address - Phone:262-796-1045
Mailing Address - Fax:
Practice Address - Street 1:16535 W BLUEMOUND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5936
Practice Address - Country:US
Practice Address - Phone:262-542-3255
Practice Address - Fax:262-821-6180
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI468-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist