1053379792 NPI number — MS. KATHLEEN A NEVILLE LCSW

Table of content: MS. KATHLEEN A NEVILLE LCSW (NPI 1053379792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053379792 NPI number — MS. KATHLEEN A NEVILLE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEVILLE
Provider First Name:
KATHLEEN
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FREDRICKS
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053379792
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3970 N OAKLAND AVE
Provider Second Line Business Mailing Address:
502
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53211-2265
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-332-9096
Provider Business Mailing Address Fax Number:
414-332-8596

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3970 N OAKLAND AVE
Provider Second Line Business Practice Location Address:
502
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53211-2265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-332-9096
Provider Business Practice Location Address Fax Number:
414-332-8596
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149010724 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 147123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01634461 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 39253100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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