Provider Demographics
NPI:1316457575
Name:DIERAUER, NANCI G
Entity type:Individual
Prefix:
First Name:NANCI
Middle Name:G
Last Name:DIERAUER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W359N5226 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3225
Mailing Address - Country:US
Mailing Address - Phone:262-347-7585
Mailing Address - Fax:
Practice Address - Street 1:2248 S 102ND ST. #155
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2147
Practice Address - Country:US
Practice Address - Phone:414-541-5100
Practice Address - Fax:844-515-9455
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3317-226101YP2500X
WI7492-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100071837Medicaid