Provider Demographics
NPI:1831202696
Name:ECKERSTORFER, RICHARD FRANK (LCSW)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:FRANK
Last Name:ECKERSTORFER
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 1:1208 SOUTH WATERTOWN STREET
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-2309
Mailing Address - Country:US
Mailing Address - Phone:920-324-4358
Mailing Address - Fax:920-324-4737
Practice Address - Street 1:1208 SOUTH WATERTOWN STREET
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-2309
Practice Address - Country:US
Practice Address - Phone:920-324-4358
Practice Address - Fax:920-324-4737
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28011231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39275100Medicaid