Provider Demographics
NPI:1972608610
Name:BRANDLI, WALTER DREW (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:DREW
Last Name:BRANDLI
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:DREW
Other - Middle Name:
Other - Last Name:BRANDLI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:430 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-4200
Mailing Address - Fax:920-926-8885
Practice Address - Street 1:430 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-4200
Practice Address - Fax:920-926-8885
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1063104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12840OtherDEAN HEALTH
WI39619800Medicaid
R79419Medicare UPIN