Provider Demographics
NPI:1730471103
Name:WALTER, DANA LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:LYNN
Last Name:WALTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1361
Mailing Address - Country:US
Mailing Address - Phone:920-563-9375
Mailing Address - Fax:920-563-9376
Practice Address - Street 1:734 MADISON AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1361
Practice Address - Country:US
Practice Address - Phone:920-563-9375
Practice Address - Fax:920-563-9376
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3116-123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39663200Medicaid