Healthcare Provider Details

I. General information

NPI: 1619110012
Provider Name (Legal Business Name): KIP CAMERON KUSSMAN B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

561 N 15TH ST 171A
MILWAUKEE WI
53233-2237
US

IV. Provider business mailing address

561 N 15TH ST 171A
MILWAUKEE WI
53233-2237
US

V. Phone/Fax

Practice location:
  • Phone: 414-288-4556
  • Fax:
Mailing address:
  • Phone: 414-288-4556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15775-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: