Basic Information
| Provider Information | |||||||||
| NPI: | 1568785558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS, LPC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 W. WISCONSIN AVENUE | ||||||||
| Address2: | MS 958 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142667615 | ||||||||
| FaxNumber: | 4142666238 | ||||||||
| Practice Location | |||||||||
| Address1: | W4063 HWY NN | ||||||||
| Address2: | |||||||||
| City: | ELKHORN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531214338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627411440 | ||||||||
| FaxNumber: | 2627432221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2010 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 4811-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1568785558 | 05 | WI | MEDICAID |