Provider Demographics
NPI:1982701991
Name:PALMERT, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:PALMERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 N GRANDVIEW BLVD
Mailing Address - Street 2:#309
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2314 N GRANDVIEW BLVD
Practice Address - Street 2:#309
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1675
Practice Address - Country:US
Practice Address - Phone:262-544-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7175-1231041C0700X
WI681-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7175-123OtherSTATE OF WISC LICENSE
WI681-124OtherSTATE OF WISC LICENSE