Provider Demographics
NPI:1376735894
Name:DEHNERT, EDWARD A (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:DEHNERT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:EDWARD
Other - Middle Name:A
Other - Last Name:DEHNERT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CSAC
Mailing Address - Street 1:1315 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-3564
Mailing Address - Country:US
Mailing Address - Phone:920-261-4100
Mailing Address - Fax:920-261-8801
Practice Address - Street 1:1315 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-3564
Practice Address - Country:US
Practice Address - Phone:920-261-4100
Practice Address - Fax:920-261-8801
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WI7575-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI15439-132OtherCLINICAL SUBSTANCE ABUSE COUNSELOR
WI7575-123OtherLICENSED CLINICAL SOCIAL WORKER