Provider Demographics
NPI:1598416240
Name:VANDERWYST, KALEENA (LPC-IT)
Entity Type:Individual
Prefix:
First Name:KALEENA
Middle Name:
Last Name:VANDERWYST
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15735 W US HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-6475
Mailing Address - Country:US
Mailing Address - Phone:715-634-2541
Mailing Address - Fax:715-934-5554
Practice Address - Street 1:730 SWEDE AVE
Practice Address - Street 2:
Practice Address - City:TURTLE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54889-0000
Practice Address - Country:US
Practice Address - Phone:715-986-2599
Practice Address - Fax:715-986-2521
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5197101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional