Provider Demographics
NPI:1770522815
Name:LATHEN, CAROLYN J (LCSW)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:J
Last Name:LATHEN
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:N91W17271 APPLETON AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2045
Mailing Address - Country:US
Mailing Address - Phone:262-502-3300
Mailing Address - Fax:
Practice Address - Street 1:N91W17271 APPLETON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2045
Practice Address - Country:US
Practice Address - Phone:262-502-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6561104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39718300Medicaid
WIQ62200Medicare UPIN
WI370Medicare ID - Type Unspecified
WI68375Medicare PIN
WI39718300Medicaid