Basic Information
| Provider Information | |||||||||
| NPI: | 1790958973 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUNOG | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | LCSW, CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HICKORY STREET | ||||||||
| Address2: | |||||||||
| City: | MAUSTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088472400 | ||||||||
| FaxNumber: | 6088479599 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HICKORY STREET | ||||||||
| Address2: | |||||||||
| City: | MAUSTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088472400 | ||||||||
| FaxNumber: | 6088479599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1594-132 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 1020 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 1020-125 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | 3191 | WI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 3191-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39273700 | 05 | WI | MEDICAID |