Provider Demographics
NPI:1437264975
Name:PETZOLD, KATHRYN ANNE (MS, LPC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:PETZOLD
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ANNE
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LPC
Mailing Address - Street 1:1212 S 70TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3105
Mailing Address - Country:US
Mailing Address - Phone:414-453-1400
Mailing Address - Fax:414-453-2538
Practice Address - Street 1:620 S 76TH ST STE 240
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-1599
Practice Address - Country:US
Practice Address - Phone:414-292-4242
Practice Address - Fax:414-292-4182
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3580125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40998700Medicaid