Provider Demographics
NPI:1376976738
Name:PROROK, KYLE J (LPC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:J
Last Name:PROROK
Suffix:
Gender:M
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:E10671 GORE HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:VIOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54664-8054
Mailing Address - Country:US
Mailing Address - Phone:608-632-9176
Mailing Address - Fax:
Practice Address - Street 1:400 CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-1309
Practice Address - Country:US
Practice Address - Phone:608-632-9176
Practice Address - Fax:608-637-8000
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1607-226101Y00000X
WI5504-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1376976738Medicaid