Basic Information
| Provider Information | |||||||||
| NPI: | 1962003707 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S HOSPITAL OF WISCONSIN | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8800 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534063701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8800 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534063701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626647423 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2020 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIEFER | ||||||||
| AuthorizedOfficialFirstName: | KATRINA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHILD AND FAMILY THERAPIST II | ||||||||
| AuthorizedOfficialTelephone: | 2629946884 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.