Provider Demographics
NPI:1154473809
Name:SIECZKOWSKI, KENNETH A (CADC-III)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:A
Last Name:SIECZKOWSKI
Suffix:
Gender:M
Credentials:CADC-III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12970 W BLUEMOUND RD
Mailing Address - Street 2:308
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2607
Mailing Address - Country:US
Mailing Address - Phone:262-780-1020
Mailing Address - Fax:262-780-1022
Practice Address - Street 1:12970 W BLUEMOUND RD
Practice Address - Street 2:308
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2607
Practice Address - Country:US
Practice Address - Phone:262-780-1020
Practice Address - Fax:262-780-1022
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13092101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)