Provider Demographics
NPI:1366567174
Name:INSIDE OUT COUNSELING AND DIAGNOSTIC CENTER, LLC
Entity type:Organization
Organization Name:INSIDE OUT COUNSELING AND DIAGNOSTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DENNISON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:920-322-9100
Mailing Address - Street 1:104 S MAIN ST
Mailing Address - Street 2:SUITE 711
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4269
Mailing Address - Country:US
Mailing Address - Phone:920-322-9100
Mailing Address - Fax:920-322-9493
Practice Address - Street 1:104 S MAIN ST
Practice Address - Street 2:SUITE 711
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4269
Practice Address - Country:US
Practice Address - Phone:920-322-9100
Practice Address - Fax:920-322-9493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2394-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty