Basic Information
| Provider Information | |||||||||
| NPI: | 1144493693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DORN | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9501 W WATERTOWN PLANK RD | ||||||||
| Address2: | PO BOX 13397 | ||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142573141 | ||||||||
| FaxNumber: | 4142573151 | ||||||||
| Practice Location | |||||||||
| Address1: | 9501 W WATERTOWN PLANK RD | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142573141 | ||||||||
| FaxNumber: | 4142573151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2008 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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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 | 1041C0700X | 6719-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39786100 | 05 | WI | MEDICAID |