Provider Demographics
NPI:1952557647
Name:HENDRICKS, CAROLYN JEAN (MD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JEAN
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:JEAN
Other - Last Name:GONTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1881 CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-3770
Mailing Address - Country:US
Mailing Address - Phone:920-403-8209
Mailing Address - Fax:
Practice Address - Street 1:1881 CHICAGO ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-3770
Practice Address - Country:US
Practice Address - Phone:920-403-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN538952084P0800X
390200000X
WI637062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNENROLLEDMedicaid
MN260003495Medicare PIN