Provider Demographics
NPI:1083261929
Name:SIMPSON, TANNER DAKOTA
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:DAKOTA
Last Name:SIMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 N 124TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2489
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 S BARSTOW ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3642
Practice Address - Country:US
Practice Address - Phone:715-832-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2024-06-03
Deactivation Date:2024-05-14
Deactivation Code:
Reactivation Date:2024-05-29
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator