Healthcare Provider Details

I. General information

NPI: 1295641587
Provider Name (Legal Business Name): SAMUEL CURTIS UFFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6121 GREEN BAY RD STE 200
KENOSHA WI
53142-2931
US

IV. Provider business mailing address

77 CHURCH RD
WINNETKA IL
60093-3946
US

V. Phone/Fax

Practice location:
  • Phone: 262-864-1141
  • Fax:
Mailing address:
  • Phone: 845-269-8584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number136363-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: