Provider Demographics
NPI:1447609086
Name:DANIELSEN, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DANIELSEN
Suffix:
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 1:301 W GRANT HWY
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152-3038
Mailing Address - Country:US
Mailing Address - Phone:815-759-7182
Mailing Address - Fax:
Practice Address - Street 1:301 W GRANT HWY
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-3038
Practice Address - Country:US
Practice Address - Phone:815-759-7182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-05
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker