Healthcare Provider Details

I. General information

NPI: 1992195192
Provider Name (Legal Business Name): RUSS KINKADE PSY D SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6214 WASHINGTON AVE C-10
MOUNT PLEASANT WI
53406-3986
US

IV. Provider business mailing address

S55W29307 HOLIDAY POINT DR
WAUKESHA WI
53189-9026
US

V. Phone/Fax

Practice location:
  • Phone: 262-989-5228
  • Fax: 262-878-9285
Mailing address:
  • Phone: 262-989-5228
  • Fax: 262-878-9285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1296
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RUSSELL WILLIAM KINKADE JR.
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 262-989-5228