Basic Information
| Provider Information | |||||||||
| NPI: | 1609361401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOUCK | ||||||||
| FirstName: | DEANNA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
| Credential: | BS, | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 322 DEWITT ST | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539012114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087459292 | ||||||||
| FaxNumber: | 6082802707 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 DEWITT ST | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539012114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087459292 | ||||||||
| FaxNumber: | 6082802707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2018 | ||||||||
| LastUpdateDate: | 06/25/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | WI | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.