Basic Information
| Provider Information | |||||||||
| NPI: | 1477612836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALCERRO | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | PH.D. | ||||||||
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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: | 409 CTY RD R | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152849477 | ||||||||
| FaxNumber: | 7152845547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2010 | ||||||||
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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 | 103TH0100X | 1949-057 | WI | Y | Behavioral Health & Social Service Providers | Psychologist | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 180056 | 01 | MN | UCARE | OTHER | 49948 | 01 | SECURITY HEALTH PLAN | OTHER | 39683800 | 05 | WI | MEDICAID |