Provider Demographics
NPI:1134281959
Name:DRUCKENBROD, DAVID W (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:W
Last Name:DRUCKENBROD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 BROOKSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-4111
Mailing Address - Country:US
Mailing Address - Phone:608-873-6422
Mailing Address - Fax:
Practice Address - Street 1:1520 VERNON ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-2260
Practice Address - Country:US
Practice Address - Phone:608-873-6422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1191-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39588800Medicaid
WI39588800Medicaid