Provider Demographics
NPI:1831385335
Name:FOSSUM, DAWN C (SOCIAL WORKER)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:C
Last Name:FOSSUM
Suffix:
Gender:F
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:C
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3530 N COUNTY RD E # F
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-9074
Mailing Address - Country:US
Mailing Address - Phone:608-758-8412
Mailing Address - Fax:
Practice Address - Street 1:3530 N COUNTY RD E # F
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-9074
Practice Address - Country:US
Practice Address - Phone:608-758-8412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8769-120104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker