Basic Information
| Provider Information | |||||||||
| NPI: | 1811480718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUERRERO | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 SCHERER AVE | ||||||||
| Address2: | |||||||||
| City: | OCONTO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541531132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204616995 | ||||||||
| FaxNumber: | 9207700524 | ||||||||
| Practice Location | |||||||||
| Address1: | 3150 GERSHWIN DR | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543114328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203914700 | ||||||||
| FaxNumber: | 9203914731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2018 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 132842-121 | WI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 16490-132 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.