Provider Demographics
NPI:1023138112
Name:DECARLO-KIENITZ, LORI ANNE (CSAC)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:ANNE
Last Name:DECARLO-KIENITZ
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-2823
Mailing Address - Country:US
Mailing Address - Phone:906-932-4329
Mailing Address - Fax:
Practice Address - Street 1:502 MAIN ST W STE 305
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-1512
Practice Address - Country:US
Practice Address - Phone:715-682-5207
Practice Address - Fax:715-682-5209
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14014-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39166400Medicaid