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General NPI Number Information
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NPI Number | 1306251640
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Entity Type | Organization
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Legal Business Name | GTN FENNIMORE, INC.
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Dates
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Enumeration Date | 06/25/2014
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Last Update Date | 09/30/2020
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Provider Practice Location Address
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Address Line | 1160 LINCOLN AVE
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City | FENNIMORE
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State | WI
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Zip | 53809-1746
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Country | US
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Telephone | 608-822-5052
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Fax | 608-822-0131
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Provider Business Mailing Address
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Address Line | 1160 LINCOLN AVE
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City | FENNIMORE
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State | WI
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Zip | 53809-1746
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Country | US
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Telephone | 608-822-5052
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Fax | 608-822-0131
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Authorized Official
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Title or Position | OWNER
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Name | REGINA ANN TROLLOP
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Credential | LCSW
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Telephone | 608-778-6978
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 384
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License Number State | WI
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