Provider Demographics
NPI:1417015025
Name:DAEHN, MICHAEL IV
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DAEHN
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2187
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54903-2187
Mailing Address - Country:US
Mailing Address - Phone:920-236-4600
Mailing Address - Fax:
Practice Address - Street 1:220 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-5030
Practice Address - Country:US
Practice Address - Phone:920-236-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1388-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42139300Medicaid
WI42139300Medicaid