Basic Information
Provider Information | |||||||||
NPI: | 1659301141 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PRZYWOJOSKI | ||||||||
FirstName: | KAY | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC CADCIII | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 WEST AVENUE SOUTH | ||||||||
Address2: | ATTN PHYSICIAN SERVICES | ||||||||
City: | LACROSSE | ||||||||
State: | WI | ||||||||
PostalCode: | 54601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087914156 | ||||||||
FaxNumber: | 6087919898 | ||||||||
Practice Location | |||||||||
Address1: | 325 BUTTS AVENUE | ||||||||
Address2: |   | ||||||||
City: | TOMAH | ||||||||
State: | WI | ||||||||
PostalCode: | 546601412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083725999 | ||||||||
FaxNumber: | 6093723436 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1400 | WI | X |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 3112 | WI | X |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 39343400 | 05 | WI |   | MEDICAID |