Provider Demographics
NPI:1245739135
Name:HERZOG, KATHY ANNE (LPC)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:ANNE
Last Name:HERZOG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 W GLEN OAKS LN STE 110
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3392
Mailing Address - Country:US
Mailing Address - Phone:262-244-6177
Mailing Address - Fax:262-299-3040
Practice Address - Street 1:11518 N PORT WASHINGTON RD STE 202
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3443
Practice Address - Country:US
Practice Address - Phone:262-244-6177
Practice Address - Fax:262-299-3040
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3764-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100075289Medicaid