Provider Demographics
NPI:1649359308
Name:TROUT, CAROL GRACE (LCSW 7269123)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:GRACE
Last Name:TROUT
Suffix:
Gender:F
Credentials:LCSW 7269123
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:GRACE
Other - Last Name:MURYN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APSW 1866121
Mailing Address - Street 1:3900 W BROWN DEER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:414-540-2170
Mailing Address - Fax:414-540-2171
Practice Address - Street 1:3900 W BROWN DEER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209
Practice Address - Country:US
Practice Address - Phone:414-540-2170
Practice Address - Fax:414-540-2171
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI72691231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41003500Medicaid