Provider Demographics
NPI:1124222492
Name:PULKRABEK, LORI ANN (CICSW)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:PULKRABEK
Suffix:
Gender:F
Credentials:CICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 EDENBERRY ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6952
Mailing Address - Country:US
Mailing Address - Phone:608-298-0451
Mailing Address - Fax:
Practice Address - Street 1:5600 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1243
Practice Address - Country:US
Practice Address - Phone:608-274-6266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI629-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical