=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346656469
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORI KROENING LCSW CSAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2014
-----------------------------------------------------
Last Update Date | 11/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2509 8TH STREET S
-----------------------------------------------------
City | WISCONSIN RAPIDS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-712-1523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3836 REDWOOD STREET
-----------------------------------------------------
City | FENWOOD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-352-2305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 16002-132
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 8634-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------