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General NPI Number Information
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NPI Number | 1992195192
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Entity Type | Organization
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Legal Business Name | RUSS KINKADE PSY D SC
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Dates
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Enumeration Date | 01/27/2015
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Last Update Date | 08/01/2025
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Provider Practice Location Address
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Address Line | 6214 WASHINGTON AVE C-10
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City | MOUNT PLEASANT
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State | WI
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Zip | 53406-3986
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Country | US
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Telephone | 262-989-5228
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Fax | 262-878-9285
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Provider Business Mailing Address
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Address Line | S55W29307 HOLIDAY POINT DR
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City | WAUKESHA
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State | WI
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Zip | 53189-9026
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Country | US
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Telephone | 262-989-5228
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Fax | 262-878-9285
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RUSSELL WILLIAM KINKADE JR.
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Credential | PSY.D.
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Telephone | 262-989-5228
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 1296
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License Number State | WI
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