Provider Demographics
NPI:1376968073
Name:DIENBERG, CANDICE NICOLE (LCSW, SAC)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:NICOLE
Last Name:DIENBERG
Suffix:
Gender:F
Credentials:LCSW, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6510 GRAND TETON PLZ STE 402
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1029
Mailing Address - Country:US
Mailing Address - Phone:855-458-4966
Mailing Address - Fax:608-841-1200
Practice Address - Street 1:6510 GRAND TETON PLZ STE 402
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1029
Practice Address - Country:US
Practice Address - Phone:855-458-4966
Practice Address - Fax:608-841-1200
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15826-131101YA0400X
WI9228-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty