Provider Demographics
NPI:1205960077
Name:KNUTZEN, LAURIE A (MSSW)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:A
Last Name:KNUTZEN
Suffix:
Gender:F
Credentials:MSSW
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:KNEISLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 JEWELERS PARK DR
Mailing Address - Street 2:STE 100
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3893
Mailing Address - Country:US
Mailing Address - Phone:715-281-1541
Mailing Address - Fax:920-720-9980
Practice Address - Street 1:40 JEWELERS PARK DR
Practice Address - Street 2:STE 100
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-3893
Practice Address - Country:US
Practice Address - Phone:715-281-1541
Practice Address - Fax:920-720-9980
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI625123101Y00000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
11810183OtherCAQH
WI39256200Medicaid
WI0003Medicare UPIN
WI39256200Medicaid