Healthcare Provider Details

I. General information

NPI: 1609361401
Provider Name (Legal Business Name): DEANNA LYNN HOUCK I BS,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 DEWITT ST
PORTAGE WI
53901-2114
US

IV. Provider business mailing address

322 DEWITT ST
PORTAGE WI
53901-2114
US

V. Phone/Fax

Practice location:
  • Phone: 608-745-9292
  • Fax: 608-280-2707
Mailing address:
  • Phone: 608-745-9292
  • Fax: 608-280-2707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10201-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: