Healthcare Provider Details

I. General information

NPI: 1063996197
Provider Name (Legal Business Name): DANA JO WEIDEMAN PC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 3RD ST S
WISC RAPIDS WI
54494-4350
US

IV. Provider business mailing address

420 3RD ST S
WISC RAPIDS WI
54494-4350
US

V. Phone/Fax

Practice location:
  • Phone: 715-712-1523
  • Fax: 715-712-0781
Mailing address:
  • Phone: 715-712-1523
  • Fax: 715-712-0781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4145-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: