Provider Demographics
NPI:1548205685
Name:SAMPLE, DANIELLE E (PSYD)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:E
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W243N5807 QUAIL RUN LN
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-3680
Mailing Address - Country:US
Mailing Address - Phone:262-695-8857
Mailing Address - Fax:262-695-8879
Practice Address - Street 1:161 W WISCONSIN AVE STE 2B
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3468
Practice Address - Country:US
Practice Address - Phone:262-695-8857
Practice Address - Fax:262-695-8879
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2476-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI392929500010OtherBCBS
WI40906600Medicaid