Provider Demographics
NPI:1619167939
Name:KOELING, CARL TYRONE (MS, LPC)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:TYRONE
Last Name:KOELING
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3008 INDIAN TRL
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-1138
Mailing Address - Country:US
Mailing Address - Phone:414-530-1441
Mailing Address - Fax:
Practice Address - Street 1:1220 MOUND AVE
Practice Address - Street 2:STE 301
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-3350
Practice Address - Country:US
Practice Address - Phone:262-633-3591
Practice Address - Fax:262-633-2619
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI831-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43718600Medicaid