1477609907 NPI number — MS. KATHY CORLETT DAHLK LCSW

Table of content: MS. KATHY CORLETT DAHLK LCSW (NPI 1477609907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477609907 NPI number — MS. KATHY CORLETT DAHLK LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAHLK
Provider First Name:
KATHY
Provider Middle Name:
CORLETT
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477609907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W62 N248 WASHINGTON AVENUE
Provider Second Line Business Mailing Address:
SUITE #207
Provider Business Mailing Address City Name:
CEDARBURG
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-375-1116
Provider Business Mailing Address Fax Number:
262-375-1071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2363 S 102ND STREET
Provider Second Line Business Practice Location Address:
SUITE #203
Provider Business Practice Location Address City Name:
WEST ALLIS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-545-1950
Provider Business Practice Location Address Fax Number:
414-545-4168
Provider Enumeration Date:
01/26/2007

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:  1148123 , 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: 40965000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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