Provider Demographics
NPI:1689745473
Name:CHRISTIANSON, DARRYL L (MS LCSW)
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:L
Last Name:CHRISTIANSON
Suffix:
Gender:M
Credentials:MS LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 W MADISON ST
Mailing Address - Street 2:OMNE CLINIC INC
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703
Mailing Address - Country:US
Mailing Address - Phone:715-832-5454
Mailing Address - Fax:715-832-2991
Practice Address - Street 1:221 W MADISON ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703
Practice Address - Country:US
Practice Address - Phone:715-832-5454
Practice Address - Fax:715-832-2991
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3684101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI111741OtherSECURITY HEALTH PLAN
WI39238400Medicaid
MNHP69916OtherHEALTH PARTNERS