Provider Demographics
NPI:1407428121
Name:KRUG, CARMEN (SLP)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:KRUG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CHEYENNE CT
Mailing Address - Street 2:
Mailing Address - City:DEFOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532-1007
Mailing Address - Country:US
Mailing Address - Phone:608-516-3702
Mailing Address - Fax:
Practice Address - Street 1:300 CHEYENNE CT
Practice Address - Street 2:
Practice Address - City:DEFOREST
Practice Address - State:WI
Practice Address - Zip Code:53532-1007
Practice Address - Country:US
Practice Address - Phone:608-516-3702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5297235Z00000X
WI5297-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist