Basic Information
| Provider Information | |||||||||
| NPI: | 1053781146 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEDERICH-ELSNER | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1499 6TH ST | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543042252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204976161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2112 MAIN ST NE | ||||||||
| Address2: | |||||||||
| City: | LOS LUNAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870317097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057171155 | ||||||||
| FaxNumber: | 5057171473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2015 | ||||||||
| LastUpdateDate: | 09/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2316-226 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | CCMH0206261 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.