Basic Information
| Provider Information | |||||||||
| NPI: | 1902316227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEST | ||||||||
| FirstName: | ROBIN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MSW, CAPSW, CSAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KONETZKE | ||||||||
| OtherFirstName: | ROBIN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MSW, CAPSW, CSAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1440 | ||||||||
| Address2: | |||||||||
| City: | WAUTOMA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549821440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207875514 | ||||||||
| FaxNumber: | 9207874737 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S TOWNLINE RD | ||||||||
| Address2: | |||||||||
| City: | WAUTOMA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549826922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207875514 | ||||||||
| FaxNumber: | 9207874737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2017 | ||||||||
| LastUpdateDate: | 10/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 15989-132 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 128991-121 | WI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.