Provider Demographics
NPI:1881716447
Name:CHRISTOFFERSEN, DENNIS (PSYD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:CHRISTOFFERSEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 S YELLOWSTONE DRIVE
Mailing Address - Street 2:SUITE #218
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719
Mailing Address - Country:US
Mailing Address - Phone:608-288-1882
Mailing Address - Fax:608-288-1892
Practice Address - Street 1:437 S YELLOWSTONE DRIVE
Practice Address - Street 2:SUITE #218
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719
Practice Address - Country:US
Practice Address - Phone:608-288-1882
Practice Address - Fax:608-288-1892
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1985057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39120000Medicaid