Provider Demographics
NPI:1316013030
Name:ANDREA KISHLINE, MARY (MSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ANDREA KISHLINE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3734 7TH AVE
Mailing Address - Street 2:SUITE 24
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140
Mailing Address - Country:US
Mailing Address - Phone:262-654-0487
Mailing Address - Fax:262-654-2434
Practice Address - Street 1:3734 7TH AVE
Practice Address - Street 2:SUITE 24
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140
Practice Address - Country:US
Practice Address - Phone:262-654-0487
Practice Address - Fax:262-654-2434
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3427123101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
8477010008Medicare ID - Type Unspecified