Provider Demographics
NPI:1639246382
Name:FONSTAD, DOROTHY A (MSE, LCSW, CADC 111)
Entity Type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:A
Last Name:FONSTAD
Suffix:
Gender:F
Credentials:MSE, LCSW, CADC 111
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3521 N MORRISON ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-1251
Mailing Address - Country:US
Mailing Address - Phone:715-214-3679
Mailing Address - Fax:920-560-6618
Practice Address - Street 1:711 N LYNNDALE DR STE 1A
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3078
Practice Address - Country:US
Practice Address - Phone:920-560-4525
Practice Address - Fax:920-560-6618
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1554101YA0400X
WI3182104100000X
WI3182-123101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39787600Medicaid