=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265740963
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COURTNEY RENEE DINGFELDER BSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2010
-----------------------------------------------------
Last Update Date | 09/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1407 SAINT ANDREW ST STE 100
-----------------------------------------------------
City | LA CROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54603-2378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-989-2736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5210 W 9TH ST
-----------------------------------------------------
City | WINONA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55987-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-458-0552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 8829-120
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------