1790985000 NPI number — DAN G FEASTER L.C.S.W. M.S.W.

Table of content: DAN G FEASTER L.C.S.W. M.S.W. (NPI 1790985000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790985000 NPI number — DAN G FEASTER L.C.S.W. M.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEASTER
Provider First Name:
DAN
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W. M.S.W.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790985000
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5900 MONONA DR
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
MONONA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53716-3556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-663-0763
Provider Business Mailing Address Fax Number:
608-663-0765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5900 MONONA DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONONA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53716-3556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-663-0763
Provider Business Practice Location Address Fax Number:
608-663-0765
Provider Enumeration Date:
07/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  2511-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1962544353 . This is a "NPI FOR SAMARITAN COUNSEL" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39567300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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