Healthcare Provider Details

I. General information

NPI: 1104863596
Provider Name (Legal Business Name): OLIN KIRK YAUCHLER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 SAYLESVILLE RD
WAUKESHA WI
53189
US

IV. Provider business mailing address

3011 SAYLESVILLE RD
WAUKESHA WI
53189
US

V. Phone/Fax

Practice location:
  • Phone: 262-928-6900
  • Fax: 262-928-3815
Mailing address:
  • Phone: 262-928-6900
  • Fax: 262-928-3815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13936131
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7117123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: