Provider Demographics
NPI:1922172675
Name:ELMERGREEN, DENNIS DEAN (PSY D)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:DEAN
Last Name:ELMERGREEN
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-2399
Mailing Address - Country:US
Mailing Address - Phone:175-675-3807
Mailing Address - Fax:
Practice Address - Street 1:W12802 COUNTY ROAD A
Practice Address - Street 2:
Practice Address - City:BOWLER
Practice Address - State:WI
Practice Address - Zip Code:54416-9551
Practice Address - Country:US
Practice Address - Phone:715-793-4144
Practice Address - Fax:715-793-4120
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1260-057103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39200800Medicaid
WI39200800Medicaid