Healthcare Provider Details

I. General information

NPI: 1215355219
Provider Name (Legal Business Name): DANIELLE GRAHAM - HEINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 ANNEX RD
JEFFERSON WI
53549-9803
US

IV. Provider business mailing address

1541 ANNEX RD
JEFFERSON WI
53549-9803
US

V. Phone/Fax

Practice location:
  • Phone: 920-674-3105
  • Fax: 920-674-6113
Mailing address:
  • Phone: 920-674-3105
  • Fax: 920-674-6113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1213-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: