Basic Information
Provider Information | |||||||||
NPI: | 1447218987 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FOGLESON | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CSAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ANDERSON | ||||||||
OtherFirstName: | CAROL | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CADCIII | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 220 E LA CROSSE ST | ||||||||
Address2: | JUNEAU COUNTY HUMAN SERVICES | ||||||||
City: | MAUSTON | ||||||||
State: | WI | ||||||||
PostalCode: | 539482101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088472400 | ||||||||
FaxNumber: | 6088479599 | ||||||||
Practice Location | |||||||||
Address1: | 220 E LA CROSSE ST | ||||||||
Address2: | JUNEAU COUNTY HUMAN SERVICES | ||||||||
City: | MAUSTON | ||||||||
State: | WI | ||||||||
PostalCode: | 539482101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088472400 | ||||||||
FaxNumber: | 6088479599 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1799132 | WI | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 1799 | WI | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 39355300 | 05 | WI |   | MEDICAID |