Provider Demographics
NPI:1508252024
Name:DIMENNA, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:DIMENNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:
Other - Last Name:DIMENNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2501 HANLEY RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8705
Mailing Address - Country:US
Mailing Address - Phone:913-424-3166
Mailing Address - Fax:
Practice Address - Street 1:2501 HANLEY RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8705
Practice Address - Country:US
Practice Address - Phone:913-424-3166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN219301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical