Healthcare Provider Details

I. General information

NPI: 1407410418
Provider Name (Legal Business Name): REBECCA ANN KERSTEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 MIDWAY RD
MENASHA WI
54952-1115
US

IV. Provider business mailing address

2807 E LOURDES DR
APPLETON WI
54915-3914
US

V. Phone/Fax

Practice location:
  • Phone: 920-720-2300
  • Fax: 920-720-3719
Mailing address:
  • Phone: 920-931-4229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9117-123
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9117
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: