Provider Demographics
NPI:1194738559
Name:HOUSELOG, BETH A (RN)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:HOUSELOG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 S LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:WI
Mailing Address - Zip Code:53110-1241
Mailing Address - Country:US
Mailing Address - Phone:414-294-4622
Mailing Address - Fax:
Practice Address - Street 1:4315 S LAKE DR
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-1241
Practice Address - Country:US
Practice Address - Phone:414-294-4622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39970000Medicaid