Basic Information
| Provider Information | |||||||||
| NPI: | 1083376289 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KARL | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | MADISON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | SAC-IT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MANEY | ||||||||
| OtherFirstName: | MIRANDA | ||||||||
| OtherMiddleName: | MADISON | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | SAC-IT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1991 E WINNEBAGO STREET | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153625745 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1991 E WINNEBAGO STREET | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153625745 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2021 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 19111 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.