Provider Demographics
NPI:1184814725
Name:ZELLER, KIM L (MS)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:L
Last Name:ZELLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5900
Mailing Address - Country:US
Mailing Address - Phone:920-832-5270
Mailing Address - Fax:920-832-5488
Practice Address - Street 1:401 S ELM ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5900
Practice Address - Country:US
Practice Address - Phone:920-832-5270
Practice Address - Fax:920-832-5488
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4403-125101YP2500X
WI15359-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39179500Medicaid