1912916750 NPI number — MRS. ELIZABETH MARY DAHLEN III MS CCC-SLP

Table of content: MRS. BONNIE ANN MCKINSEY ARNP (NPI 1558337774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912916750 NPI number — MRS. ELIZABETH MARY DAHLEN III MS CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAHLEN
Provider First Name:
ELIZABETH
Provider Middle Name:
MARY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
III
Provider Credential Text:
MS CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLEMENTS
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS CCC-SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912916750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 RAMSLAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTBY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54667-1031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-634-2352
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2935 EAST AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA CROSSE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54601-7243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-787-5572
Provider Business Practice Location Address Fax Number:
608-787-7775
Provider Enumeration Date:
08/07/2006

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: 235Z00000X , with the licence number:  2274-154 , 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)





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