MEDICARE: JAMES KINTA SUMMERALL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	101YM0800	WI
2	101YM0800X	Mental Health Counselor	1381-26202844	WI

General Provider Information

NPI Number	:	1184441578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES KINTA SUMMERALL

Provider Business Mailing Address
First Line	:	2655 N FRATNEY ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-2950
Country	:	US
Telephone Number	:	414-791-4996
Fax Number	:

Provider Business Practice Location Address
First Line	:	2655 N FRATNEY ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-2950
Country	:	US
Telephone Number	:	414-791-4996
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2024
Last Update Date	:	09/25/2024

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