Provider Demographics
NPI:1477114874
Name:BERKEN, KATELYN
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:BERKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 S 76TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1599
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 120
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-1599
Practice Address - Country:US
Practice Address - Phone:414-453-1400
Practice Address - Fax:414-453-2538
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8140-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1477114874Medicaid