Basic Information
| Provider Information | |||||||||
| NPI: | 1366912248 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINX | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | SAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CONGLETON | ||||||||
| OtherFirstName: | KAREN | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3144 VANZILE ROAD | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545208149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154785180 | ||||||||
| FaxNumber: | 7154785904 | ||||||||
| Practice Location | |||||||||
| Address1: | 3144 VANZILE ROAD | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545208149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154785180 | ||||||||
| FaxNumber: | 7154785904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2018 | ||||||||
| LastUpdateDate: | 06/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 16492 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 18719-130 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 100092088 | 05 | WI | MEDICAID |