1649359308 NPI number — CAROL GRACE TROUT LCSW 7269123

Table of content: CAROL GRACE TROUT LCSW 7269123 (NPI 1649359308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649359308 NPI number — CAROL GRACE TROUT LCSW 7269123

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TROUT
Provider First Name:
CAROL
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW 7269123
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MURYN
Provider Other First Name:
CAROL
Provider Other Middle Name:
GRACE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APSW 1866121
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1649359308
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3900 W BROWN DEER RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BROWN DEER
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-540-2170
Provider Business Mailing Address Fax Number:
414-540-2171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3900 W BROWN DEER RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BROWN DEER
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-540-2170
Provider Business Practice Location Address Fax Number:
414-540-2171
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  7269123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 41003500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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