Basic Information
| Provider Information | |||||||||
| NPI: | 1164535324 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHAFER | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 E 3RD ST | ||||||||
| Address2: | 2 | ||||||||
| City: | WINONA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559873478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074527292 | ||||||||
| FaxNumber: | 5074579887 | ||||||||
| Practice Location | |||||||||
| Address1: | 1707 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546014200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087886322 | ||||||||
| FaxNumber: | 6087850002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 01/08/2008 | ||||||||
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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 | 3847-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 63-124 | WI | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 39281800 | 05 | WI | MEDICAID | 016L6SC | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER |