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General NPI Number Information
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NPI Number | 1366567174
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Entity Type | Organization
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Legal Business Name | INSIDE OUT COUNSELING AND DIAGNOSTIC CENTER, LLC
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 104 S MAIN ST SUITE 711
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City | FOND DU LAC
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State | WI
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Zip | 54935-4269
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Country | US
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Telephone | 920-322-9100
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Fax | 920-322-9493
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Provider Business Mailing Address
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Address Line | 104 S MAIN ST SUITE 711
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City | FOND DU LAC
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State | WI
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Zip | 54935-4269
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Country | US
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Telephone | 920-322-9100
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Fax | 920-322-9493
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Authorized Official
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Title or Position | OWNER
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Name | DR. PEGGY A DENNISON
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Credential | PHD.
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Telephone | 920-322-9100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2394-057
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License Number State | WI
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