Provider Demographics
NPI:1417718685
Name:ZIMMERMAN, KYLIE AINE (LMFT-IT)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:AINE
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:LMFT-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 RUGGLES ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3929
Mailing Address - Country:US
Mailing Address - Phone:920-344-8438
Mailing Address - Fax:
Practice Address - Street 1:2211 OREGON ST STE N
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-7001
Practice Address - Country:US
Practice Address - Phone:920-479-1996
Practice Address - Fax:920-479-1997
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1024-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist