Provider Demographics
NPI:1265479257
Name:ANDERSON, DENNIS J (LCSW CADCIII)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCSW CADCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2075
Mailing Address - Country:US
Mailing Address - Phone:262-284-5789
Mailing Address - Fax:262-284-5907
Practice Address - Street 1:1317 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2075
Practice Address - Country:US
Practice Address - Phone:262-284-5789
Practice Address - Fax:262-284-5907
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2249101YA0400X
WI3072-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39730700Medicaid