Healthcare Provider Details

I. General information

NPI: 1316457575
Provider Name (Legal Business Name): NANCI G DIERAUER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 09/30/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2248 S 102ND ST. #155
WEST ALLIS WI
53227-2147
US

IV. Provider business mailing address

W359N5226 CRESTVIEW DR
OCONOMOWOC WI
53066-3225
US

V. Phone/Fax

Practice location:
  • Phone: 414-541-5100
  • Fax: 844-515-9455
Mailing address:
  • Phone: 262-347-7585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3317-226
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7492-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: