Healthcare Provider Details

I. General information

NPI: 1255408043
Provider Name (Legal Business Name): DEBRA LYNNE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 02/06/2021
Certification Date: 02/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W EDISON AVE STE 215
APPLETON WI
54915-1390
US

IV. Provider business mailing address

101 W EDISON AVE STE 215
APPLETON WI
54915-1390
US

V. Phone/Fax

Practice location:
  • Phone: 920-410-9036
  • Fax:
Mailing address:
  • Phone: 920-410-9036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6899-123
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6899
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: