Basic Information
| Provider Information | |||||||||
| NPI: | 1083790240 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DITTLOFF | ||||||||
| FirstName: | DEANNA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22040 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 ANGELS PATH | ||||||||
| Address2: | |||||||||
| City: | DE PERE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541154050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203382855 | ||||||||
| FaxNumber: | 9203389270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5795-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.