Healthcare Provider Details

I. General information

NPI: 1982987368
Provider Name (Legal Business Name): KENNETH G UTECH MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3313 PACKERLAND DR SUITE D
DE PERE WI
54115-6810
US

IV. Provider business mailing address

3313 PACKERLAND DR SUITE D
DE PERE WI
54115-6810
US

V. Phone/Fax

Practice location:
  • Phone: 920-983-0707
  • Fax: 920-983-0700
Mailing address:
  • Phone: 920-983-0707
  • Fax: 920-983-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number393-123
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number74124
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: