Basic Information
| Provider Information | |||||||||
| NPI: | 1467448290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ECKERT | ||||||||
| FirstName: | KAYE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 FOSSE CT | ||||||||
| Address2: | |||||||||
| City: | NEKOOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544578799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153252852 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 108 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | FRIENDSHIP | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539349443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083394511 | ||||||||
| FaxNumber: | 6083394593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | WI 2093 | WI | X | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 2093 | WI | X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39724000 | 05 | WI | MEDICAID |