Basic Information
| Provider Information | |||||||||
| NPI: | 1619023090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZIRKEL | ||||||||
| FirstName: | KIP | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZIRKEL | ||||||||
| OtherFirstName: | CLIFFORD | ||||||||
| OtherMiddleName: | HERBERT | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | III | ||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1707 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546014200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087850001 | ||||||||
| FaxNumber: | 6087850002 | ||||||||
| Practice Location | |||||||||
| Address1: | 1707 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546014200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087850001 | ||||||||
| FaxNumber: | 6087850002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 07/29/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 781 | WI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TF0200X | 781 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Forensic |
ID Information
| ID | Type | State | Issuer | Description | 39018600 | 05 | WI | MEDICAID | HP69927 | 01 | HEALTHPARTNERS | OTHER | 13G9521 | 01 | MN | BCBS-MN | OTHER | 31097 | 01 | WI | NAT. REGIS. OF H.C. PROV. | OTHER | 852578100 | 05 | MN | MEDICAID |