Provider Demographics
NPI:1972726370
Name:WEEDEN, DENNIS CLARK (MSSW,LCSW, CEAP)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:CLARK
Last Name:WEEDEN
Suffix:
Gender:M
Credentials:MSSW,LCSW, CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W62N248 WASHINGTON AVE
Mailing Address - Street 2:SUITE#207
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2768
Mailing Address - Country:US
Mailing Address - Phone:262-375-1116
Mailing Address - Fax:262-375-1071
Practice Address - Street 1:W62N248 WASHINGTON AVE
Practice Address - Street 2:SUITE#207
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2768
Practice Address - Country:US
Practice Address - Phone:262-375-1116
Practice Address - Fax:262-375-1071
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI432-123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39590200Medicaid