Healthcare Provider Details

I. General information

NPI: 1578897278
Provider Name (Legal Business Name): LORI M. DOLLEVOET LCSW, LPC, SAP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 PARK PL SUITE 200
APPLETON WI
54914-8276
US

IV. Provider business mailing address

E7911 PUURI RD
FREMONT WI
54940-9755
US

V. Phone/Fax

Practice location:
  • Phone: 920-339-2000
  • Fax:
Mailing address:
  • Phone: 920-667-5215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC 342-125
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 1985-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: