Basic Information
| Provider Information | |||||||||
| NPI: | 1881758928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINNEY | ||||||||
| FirstName: | RAY | ||||||||
| MiddleName: | WOODSON | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | W344S8780 WHITETAIL DR | ||||||||
| Address2: | |||||||||
| City: | EAGLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531192318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623915561 | ||||||||
| FaxNumber: | 2625420823 | ||||||||
| Practice Location | |||||||||
| Address1: | 741 N GRAND AVE | ||||||||
| Address2: | #302 | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531864820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625423255 | ||||||||
| FaxNumber: | 2625420823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 4034-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 4034-123 | 01 | WI | LICENSED CLINICAL SOCIAL | OTHER |