Basic Information
Provider Information | |||||||||
NPI: | 1558874180 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KESTING | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC-IT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DENTICE | ||||||||
OtherFirstName: | SAMANTHA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | W175N11120 STONEWOOD DR | ||||||||
Address2: |   | ||||||||
City: | GERMANTOWN | ||||||||
State: | WI | ||||||||
PostalCode: | 530226511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004381772 | ||||||||
FaxNumber: | 2622939737 | ||||||||
Practice Location | |||||||||
Address1: | 112 PEACE LUTHERAN PKWY | ||||||||
Address2: |   | ||||||||
City: | HARTFORD | ||||||||
State: | WI | ||||||||
PostalCode: | 530271159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004381772 | ||||||||
FaxNumber: | 2622939737 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/06/2017 | ||||||||
LastUpdateDate: | 01/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 8406-125 | WI | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 3741-226 | WI | N |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 100073005 | 05 | WI |   | MEDICAID |