Healthcare Provider Details

I. General information

NPI: 1609089820
Provider Name (Legal Business Name): KIMBERLY NICOLE REZARCH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E WISCONSIN AVE STE 204A
OCONOMOWOC WI
53066-3058
US

IV. Provider business mailing address

PO BOX 432
OCONOMOWOC WI
53066-0432
US

V. Phone/Fax

Practice location:
  • Phone: 920-253-5523
  • Fax:
Mailing address:
  • Phone: 920-253-5523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12902-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: