Provider Demographics
NPI:1194789032
Name:STOLLDORF, DEAN EDWARD (PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:EDWARD
Last Name:STOLLDORF
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 MILWAUKEE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1230
Mailing Address - Country:US
Mailing Address - Phone:262-767-0440
Mailing Address - Fax:262-767-0777
Practice Address - Street 1:441 MILWAUKEE AVE STE 2
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1230
Practice Address - Country:US
Practice Address - Phone:262-767-0440
Practice Address - Fax:262-767-0777
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1243057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39071100Medicaid
WI39071100Medicaid
WI000088108Medicare ID - Type Unspecified