Provider Demographics
NPI:1477133510
Name:MODESTI, KERAH MAE (LPC-IT)
Entity Type:Individual
Prefix:
First Name:KERAH
Middle Name:MAE
Last Name:MODESTI
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:KERAH
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6233 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7015
Mailing Address - Country:US
Mailing Address - Phone:262-654-1004
Mailing Address - Fax:
Practice Address - Street 1:2108 63RD ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-4454
Practice Address - Country:US
Practice Address - Phone:262-652-2406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WI10155-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor