Healthcare Provider Details

I. General information

NPI: 1053760140
Provider Name (Legal Business Name): MRS. ATHENA KJELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ATHENA MROTEK

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2607 N GRANDVIEW BLVD STE 110
WAUKESHA WI
53188-1690
US

IV. Provider business mailing address

2607 N GRANDVIEW BLVD STE 110
WAUKESHA WI
53188-1690
US

V. Phone/Fax

Practice location:
  • Phone: 262-313-8339
  • Fax:
Mailing address:
  • Phone: 262-313-8339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6811-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: