Provider Demographics
NPI:1942338041
Name:HERRICK, DALE R (LCSW)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:R
Last Name:HERRICK
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 1:4305 TYDL DR
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2116
Mailing Address - Country:US
Mailing Address - Phone:608-757-5373
Mailing Address - Fax:
Practice Address - Street 1:3506 N US HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0726
Practice Address - Country:US
Practice Address - Phone:608-757-5373
Practice Address - Fax:608-758-8428
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2028 123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39195400Medicaid