Healthcare Provider Details

I. General information

NPI: 1881778884
Provider Name (Legal Business Name): DAVID A KUYKENDALL LCSW CADC III CCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W MAIN ST SUITE 300 PHOENIX COUNSELING
SUN PRAIRIE WI
53590
US

IV. Provider business mailing address

N 5584 CTY HWY A
LAKE MILLS WI
53551
US

V. Phone/Fax

Practice location:
  • Phone: 608-825-6711
  • Fax: 608-834-6499
Mailing address:
  • Phone: 608-825-6711
  • Fax: 608-834-6499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number645123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: