MEDICARE: MS. VANESSA DIANA STATAM LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	9892-123	WI

General Provider Information

NPI Number	:	1659926509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VANESSA DIANA STATAM LCSW

Provider Business Mailing Address
First Line	:	815 FORWARD DRIVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53711-2443
Country	:	US
Telephone Number	:	608-268-6530
Fax Number	:	608-709-1744

Provider Business Practice Location Address
First Line	:	2701 INTERNATIONAL LN STE 201
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53704-3126
Country	:	US
Telephone Number	:	608-268-6530
Fax Number	:	608-709-1744

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2019
Last Update Date	:	02/04/2026

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