Basic Information
| Provider Information | |||||||||
| NPI: | 1659431534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VOGT | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | LANEY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16535 W BLUEMOUND RD | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530055936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627891191 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4811 S 76TH ST | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532204364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148170441 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 405-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39290400 | 05 | WI | MEDICAID |