Provider Demographics
NPI:1508137712
Name:FASBENDER, KENNETH D (CSAC, SCIT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:FASBENDER
Suffix:
Gender:M
Credentials:CSAC, SCIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9433 COUNTY RD J
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-9318
Mailing Address - Country:US
Mailing Address - Phone:715-356-5377
Mailing Address - Fax:715-356-5378
Practice Address - Street 1:9433 COUNTY RD J
Practice Address - Street 2:
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548-9318
Practice Address - Country:US
Practice Address - Phone:715-356-5377
Practice Address - Fax:715-356-5378
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13112-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)