Provider Demographics
NPI:1225522089
Name:BARTHELS, KODI DENISE (SAC-IT)
Entity Type:Individual
Prefix:
First Name:KODI
Middle Name:DENISE
Last Name:BARTHELS
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:KODI
Other - Middle Name:
Other - Last Name:FREIBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23 W SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-2342
Mailing Address - Country:US
Mailing Address - Phone:920-926-0101
Mailing Address - Fax:920-926-0060
Practice Address - Street 1:23 W SCOTT ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2342
Practice Address - Country:US
Practice Address - Phone:920-926-0101
Practice Address - Fax:920-926-0060
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18609-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI18609-130Medicaid