Provider Demographics
NPI:1255484564
Name:KIRK, LINDA J (MSE, LPC, CSAC)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:J
Last Name:KIRK
Suffix:
Gender:F
Credentials:MSE, LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-3337
Mailing Address - Country:US
Mailing Address - Phone:262-299-9780
Mailing Address - Fax:877-810-4188
Practice Address - Street 1:215 N MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3337
Practice Address - Country:US
Practice Address - Phone:262-299-9780
Practice Address - Fax:877-810-4188
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2934-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43579100Medicaid