Provider Demographics
NPI:1609367853
Name:KLENNER, CARMEN REGINA
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:REGINA
Last Name:KLENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13035 W BLUEMOUND RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-8001
Mailing Address - Country:US
Mailing Address - Phone:262-784-1121
Mailing Address - Fax:
Practice Address - Street 1:13035 W BLUEMOUND RD STE 100
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-8001
Practice Address - Country:US
Practice Address - Phone:262-784-1121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 390200000X, 101YM0800X
WI101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1609367853Medicaid