Basic Information
| Provider Information | |||||||||
| NPI: | 1013190743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LICHLITER | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1707 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546014200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087850001 | ||||||||
| FaxNumber: | 6087850002 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WINONA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559873822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074539563 | ||||||||
| FaxNumber: | 5074539562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2007 | ||||||||
| LastUpdateDate: | 08/30/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 18529 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 33P33LI | 01 | MN | BCBS-MN | OTHER | 876638100 | 05 | MN | MEDICAID |