NPIMap

Individual provider Active NPI

Dorothy A Fonstad, MSE, LCSW, CADC 111

  • Social Worker
  • Appleton, WI
National Provider Identifier
1639246382
Registry record updated Feb 21, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Social WorkerTaxonomy code 104100000X
License
3182 Issued in WI
Practice address
711 N Lynndale Dr Ste 1a
Appleton, WI 54914-3078
Phone
(920) 560-4525
Fax
(920) 560-6618
NPI assigned
Nov 29, 2006
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 21, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) Counselor 101YA0400X 1554 WI
Social Worker 104100000X 3182 WI Primary
Counselor 101Y00000X 3182-123 WI

Addresses

Primary practice location

711 N Lynndale Dr Ste 1a
Appleton, WI 54914-3078

Mailing address

3521 N Morrison St
Appleton, WI 54911-1251
Phone (715) 214-3679

Other identifiers 1

IdentifierTypeStateIssuer
39787600MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
3182-123WIMDCounselor
1554WIMDAddiction (Substance Use Disorder) Counselor

Practice roles

OrganizationSpecialtyStatusNew patients
GJB Health Services, LLC PastSince May 27, 2015 Accepting new patients
GJB Eeg Services, SC PastSince Jul 4, 2021 Accepting new patients

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/22083/brand/1/csg/1/fhir/r4

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1164758400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1519171200000",
    "number": "1639246382",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3521 N MORRISON ST",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "549111251",
            "telephone_number": "715-214-3679",
            "fax_number": "920-560-6618"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "711 N LYNNDALE DR STE 1A",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "549143078",
            "telephone_number": "920-560-4525",
            "fax_number": "920-560-6618"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FONSTAD",
        "first_name": "DOROTHY",
        "middle_name": "A",
        "name_prefix": "Ms.",
        "credential": "MSE, LCSW, CADC 111",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-11-29",
        "last_updated": "2018-02-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "WI",
            "license": "1554",
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "WI",
            "license": "3182",
            "primary": true
        },
        {
            "code": "101Y00000X",
            "taxonomy_group": "",
            "desc": "Counselor",
            "state": "WI",
            "license": "3182-123",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "39787600",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Appleton, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 21, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.