MEDICARE: MRS. TORY PHONSAVAN KOETTERHAGEN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	8075-123	WI

General Provider Information

NPI Number	:	1093281370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TORY PHONSAVAN KOETTERHAGEN LCSW

Provider Business Mailing Address
First Line	:	W236S4564 WHISPERING HILLS CT
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53189-9772
Country	:	US
Telephone Number	:	414-467-6994
Fax Number	:

Provider Business Practice Location Address
First Line	:	W236S4564 WHISPERING HILLS CT
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53189-9772
Country	:	US
Telephone Number	:	414-467-6994
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2018
Last Update Date	:	10/15/2018

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