Provider Demographics
NPI:1770002214
Name:JUSULA, DANE (LCSW)
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:
Last Name:JUSULA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1639 PAVELSKI RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-9047
Mailing Address - Country:US
Mailing Address - Phone:705-661-2983
Mailing Address - Fax:
Practice Address - Street 1:475 CHIPPEWA MALL DR
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-5034
Practice Address - Country:US
Practice Address - Phone:715-720-3780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8737-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical