=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275962821
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARRIEANN ZONDAG MSW, CAPSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2013
-----------------------------------------------------
Last Update Date | 11/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 883 ST ALBERT DR
-----------------------------------------------------
City | SUN PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53590-4433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-373-8996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 883 ST ALBERT DR
-----------------------------------------------------
City | SUN PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53590-4433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-373-8996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 128319-121
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 128319-121
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 128319-121
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------