Provider Demographics
NPI:1679872576
Name:CUSTER, CAROLYN BETH (LAC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:BETH
Last Name:CUSTER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 S MAIN ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-1657
Mailing Address - Country:US
Mailing Address - Phone:920-674-6707
Mailing Address - Fax:920-674-6707
Practice Address - Street 1:112 S MAIN ST STE 2A
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-1657
Practice Address - Country:US
Practice Address - Phone:920-674-6707
Practice Address - Fax:920-674-6707
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI636-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679872576OtherCMS