Healthcare Provider Details

I. General information

NPI: 1336658202
Provider Name (Legal Business Name): KAREN OAKLAY KUSSLER SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2017
Last Update Date: 09/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 W BURLEIGH ST
MILWAUKEE WI
53210-1623
US

IV. Provider business mailing address

539 BEECHWOOD DR
CEDARBURG WI
53012-9007
US

V. Phone/Fax

Practice location:
  • Phone: 414-810-0550
  • Fax:
Mailing address:
  • Phone: 262-370-2170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18273-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: