Provider Demographics
NPI:1174796775
Name:MCDOUGAL, CAROL L (SLP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:MCDOUGAL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2758
Mailing Address - Country:US
Mailing Address - Phone:715-623-9101
Mailing Address - Fax:
Practice Address - Street 1:230 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2758
Practice Address - Country:US
Practice Address - Phone:715-623-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI132154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42654600Medicaid