Provider Demographics
NPI:1306251640
Name:GTN FENNIMORE, INC.
Entity type:Organization
Organization Name:GTN FENNIMORE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TROLLOP
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:608-778-6978
Mailing Address - Street 1:1160 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:FENNIMORE
Mailing Address - State:WI
Mailing Address - Zip Code:53809-1746
Mailing Address - Country:US
Mailing Address - Phone:608-822-5052
Mailing Address - Fax:608-822-0131
Practice Address - Street 1:1160 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FENNIMORE
Practice Address - State:WI
Practice Address - Zip Code:53809-1746
Practice Address - Country:US
Practice Address - Phone:608-822-5052
Practice Address - Fax:608-822-0131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39613700Medicaid