Provider Demographics
NPI:1033295571
Name:KINKADE, RUSSELL WILLIAM JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WILLIAM
Last Name:KINKADE
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:RUSS
Other - Middle Name:
Other - Last Name:KINKADE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYDSC
Mailing Address - Street 1:S55W29307 HOLIDAY POINT
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-9026
Mailing Address - Country:US
Mailing Address - Phone:262-989-5228
Mailing Address - Fax:
Practice Address - Street 1:6214 WASHINGTON AVENUE
Practice Address - Street 2:SUITE C 10
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406
Practice Address - Country:US
Practice Address - Phone:262-989-5228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical