Provider Demographics
NPI:1407045966
Name:LARSONKERKMAN, KERRIE JO (CSAC)
Entity Type:Individual
Prefix:
First Name:KERRIE
Middle Name:JO
Last Name:LARSONKERKMAN
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 JEWELERS PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3893
Mailing Address - Country:US
Mailing Address - Phone:920-205-8336
Mailing Address - Fax:
Practice Address - Street 1:1531 S MADISON ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1800
Practice Address - Country:US
Practice Address - Phone:920-738-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2153-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)