1881778884 NPI number — MR. DAVID A KUYKENDALL LCSW CADC III CCS

Table of content: MR. DAVID A KUYKENDALL LCSW CADC III CCS (NPI 1881778884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881778884 NPI number — MR. DAVID A KUYKENDALL LCSW CADC III CCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUYKENDALL
Provider First Name:
DAVID
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW CADC III CCS
Provider Gender Code:
M

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:
1881778884
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:
N 5584 CTY HWY A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE MILLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-825-6711
Provider Business Mailing Address Fax Number:
608-834-6499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 300 PHOENIX COUNSELING
Provider Business Practice Location Address City Name:
SUN PRAIRIE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53590
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-825-6711
Provider Business Practice Location Address Fax Number:
608-834-6499
Provider Enumeration Date:
10/25/2006

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:  645123 , 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: 645123 . This is a "STATE OF WI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 220 . This is a "STATE OF WI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39517000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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