Provider Demographics
NPI:1336134824
Name:FOSS, CAROL J (PH D)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:J
Last Name:FOSS
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 970
Mailing Address - Street 2:
Mailing Address - City:KESHENA
Mailing Address - State:WI
Mailing Address - Zip Code:54135-0970
Mailing Address - Country:US
Mailing Address - Phone:714-799-5451
Mailing Address - Fax:715-799-5854
Practice Address - Street 1:W3275
Practice Address - Street 2:WOLF RIVER ROAD
Practice Address - City:KESHENA
Practice Address - State:WI
Practice Address - Zip Code:54135
Practice Address - Country:US
Practice Address - Phone:715-799-5451
Practice Address - Fax:715-799-5854
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1945103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39127300Medicaid
P17125Medicare UPIN