Provider Demographics
NPI:1295834539
Name:KOEPKE, KATHLEEN GUSSLER (MSSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:GUSSLER
Last Name:KOEPKE
Suffix:
Gender:F
Credentials:MSSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 PARK ST
Mailing Address - Street 2:PO BOX 1230
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-9031
Mailing Address - Country:US
Mailing Address - Phone:920-787-6550
Mailing Address - Fax:920-787-0421
Practice Address - Street 1:230 W PARK ST
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-9031
Practice Address - Country:US
Practice Address - Phone:920-787-6550
Practice Address - Fax:920-787-0421
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2337101YM0800X
WI2337-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39654800Medicaid
WI84306005OtherMEDICARE