Basic Information
| Provider Information | |||||||||
| NPI: | 1194965590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DITTLOFF | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | MS, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1866 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543051866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457210 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 ARBUTUS AVE | ||||||||
| Address2: | |||||||||
| City: | OCONTO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541532004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208348833 | ||||||||
| FaxNumber: | 9208348830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2009 | ||||||||
| LastUpdateDate: | 11/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 64969 | TX | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 8608-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.