Provider Demographics
NPI:1053781146
Name:DEDERICH-ELSNER, DEBRA (LPCC)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:DEDERICH-ELSNER
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-2252
Mailing Address - Country:US
Mailing Address - Phone:920-497-6161
Mailing Address - Fax:
Practice Address - Street 1:2112 MAIN ST NE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7097
Practice Address - Country:US
Practice Address - Phone:505-717-1155
Practice Address - Fax:505-717-1473
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2316-226101YP2500X
NMCCMH0206261101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional