Provider Demographics
NPI:1346469384
Name:POMEROY, KENNA RUTH (CAPSW, CADC-D)
Entity Type:Individual
Prefix:MS
First Name:KENNA
Middle Name:RUTH
Last Name:POMEROY
Suffix:
Gender:F
Credentials:CAPSW, CADC-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3166A S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4525
Mailing Address - Country:US
Mailing Address - Phone:414-727-6320
Mailing Address - Fax:414-727-6321
Practice Address - Street 1:210 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1123
Practice Address - Country:US
Practice Address - Phone:414-727-6320
Practice Address - Fax:414-727-6321
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14804-13L101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39176500Medicaid
WI14804-13LOtherCADC-D