Provider Demographics
NPI:1114983319
Name:DEFOE, DONNA B (LCSW)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:B
Last Name:DEFOE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1911
Mailing Address - Country:US
Mailing Address - Phone:608-252-8000
Mailing Address - Fax:608-283-7193
Practice Address - Street 1:1313 FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715
Practice Address - Country:US
Practice Address - Phone:608-252-8000
Practice Address - Fax:608-283-7193
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6565-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1114983319Medicaid
WI6503OtherDEAN HEALTH INSURANCE
WI054374150Medicare PIN
WI800007659Medicare PIN
R21185Medicare UPIN