Provider Demographics
NPI:1568790954
Name:KETTLE MORAINE COUNSELING LLC
Entity Type:Organization
Organization Name:KETTLE MORAINE COUNSELING LLC
Other - Org Name:KETTLE MORAINE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEVONA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:MS LPC NCC
Authorized Official - Phone:262-334-4340
Mailing Address - Street 1:400 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53090-1567
Mailing Address - Country:US
Mailing Address - Phone:262-334-4340
Mailing Address - Fax:262-334-4341
Practice Address - Street 1:400 W RIVER DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53090-1567
Practice Address - Country:US
Practice Address - Phone:262-334-4340
Practice Address - Fax:262-334-4341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-24
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3514-125251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health