Provider Demographics
NPI:1750476990
Name:KLUTH, ELAINE CATHERINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:CATHERINE
Last Name:KLUTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22040
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2040
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:3263 EATON RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6830
Practice Address - Country:US
Practice Address - Phone:920-433-6700
Practice Address - Fax:920-433-6738
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70391231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40939700Medicaid
WIP01305539Medicare Oscar/Certification
WI008770099Medicare Oscar/Certification