Healthcare Provider Details

I. General information

NPI: 1568790954
Provider Name (Legal Business Name): KETTLE MORAINE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W RIVER DR
WEST BEND WI
53090-1567
US

IV. Provider business mailing address

400 W RIVER DR
WEST BEND WI
53090-1567
US

V. Phone/Fax

Practice location:
  • Phone: 262-334-4340
  • Fax: 262-334-4341
Mailing address:
  • Phone: 262-334-4340
  • Fax: 262-334-4341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number3514-125
License Number StateWI

VIII. Authorized Official

Name: DEVONA LYNN MARSHALL
Title or Position: OWNER/DIRECTOR
Credential: MS LPC NCC
Phone: 262-334-4340