Provider Demographics
NPI:1316581010
Name:OLDENBURG, DANICA RAE (LPC-IT)
Entity type:Individual
Prefix:
First Name:DANICA
Middle Name:RAE
Last Name:OLDENBURG
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 RIB MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-7473
Mailing Address - Country:US
Mailing Address - Phone:715-301-0667
Mailing Address - Fax:
Practice Address - Street 1:2804 RIB MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-7473
Practice Address - Country:US
Practice Address - Phone:715-301-0667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4509-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100086714Medicaid