Provider Demographics
NPI:1609368984
Name:KURTH, LAURIE
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:KURTH
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 1:728 TAYCO ST
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-2280
Mailing Address - Country:US
Mailing Address - Phone:920-830-9420
Mailing Address - Fax:
Practice Address - Street 1:3301 N BALLARD RD STE B
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-9002
Practice Address - Country:US
Practice Address - Phone:920-753-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-03
Last Update Date:2018-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18373-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)