Provider Demographics
NPI:1992715189
Name:WESLEY, CAROL J (MS)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:J
Last Name:WESLEY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 MAPLE HILL DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3767
Mailing Address - Country:US
Mailing Address - Phone:715-845-4900
Mailing Address - Fax:715-845-4970
Practice Address - Street 1:2600 STEWART AVE
Practice Address - Street 2:SUITE 38
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4148
Practice Address - Country:US
Practice Address - Phone:715-845-4900
Practice Address - Fax:715-845-4970
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI443-125101YP2500X
WI540-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39634000Medicaid