Healthcare Provider Details

I. General information

NPI: 1497347884
Provider Name (Legal Business Name): COLLEEN KICKBUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: COLLEEN CURTIS

II. Dates (important events)

Enumeration Date: 02/07/2021
Last Update Date: 02/07/2021
Certification Date: 02/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9231 W MOUNT VERNON AVE
MILWAUKEE WI
53226-4408
US

IV. Provider business mailing address

9231 W MOUNT VERNON AVE
MILWAUKEE WI
53226-4408
US

V. Phone/Fax

Practice location:
  • Phone: 224-321-7007
  • Fax:
Mailing address:
  • Phone: 224-321-7007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: