Provider Demographics
NPI:1346590452
Name:DUNHAM, LISA (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DUNHAM
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 1:1541 ANNEX RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-9803
Mailing Address - Country:US
Mailing Address - Phone:920-674-7424
Mailing Address - Fax:920-674-7409
Practice Address - Street 1:1541 ANNEX RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-9803
Practice Address - Country:US
Practice Address - Phone:920-674-7424
Practice Address - Fax:920-674-7409
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7851-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical