Provider Demographics
NPI:1730272642
Name:KRUK, JULIE ANN (LPC)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:ANN
Last Name:KRUK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 EAST GREEN BAY ST.
Mailing Address - Street 2:SUITE 191
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-3881
Mailing Address - Country:US
Mailing Address - Phone:715-526-5466
Mailing Address - Fax:715-526-5545
Practice Address - Street 1:444 SOUTH ADAMS ST.
Practice Address - Street 2:SUITE 6
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:715-526-5466
Practice Address - Fax:715-526-5545
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1450125101Y00000X
WI1450-125104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
11565088OtherCAQH
WI41003100Medicaid