Provider Demographics
NPI:1750576385
Name:CLAYCOMB, ELEANOR KLINE (MED LCSW)
Entity type:Individual
Prefix:MRS
First Name:ELEANOR
Middle Name:KLINE
Last Name:CLAYCOMB
Suffix:
Gender:F
Credentials:MED LCSW
Other - Prefix:MRS
Other - First Name:ELEANOR
Other - Middle Name:KLINE
Other - Last Name:CLAYCOMB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:504 LAKELAND RD
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-3836
Mailing Address - Country:US
Mailing Address - Phone:715-526-5547
Mailing Address - Fax:715-526-5542
Practice Address - Street 1:504 LAKELAND RD
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3836
Practice Address - Country:US
Practice Address - Phone:715-526-5547
Practice Address - Fax:715-526-5542
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4296-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39212900Medicaid
WI000084766Medicare PIN