Basic Information
| Provider Information | |||||||||
| NPI: | 1174623466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OOSTEN | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 N 25TH ST E | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548805269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153928216 | ||||||||
| FaxNumber: | 7153926055 | ||||||||
| Practice Location | |||||||||
| Address1: | 39 N 25TH ST E | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548805269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153928216 | ||||||||
| FaxNumber: | 7153926055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 585 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 39748700 | 05 | WI | MEDICAID |