Provider Demographics
NPI:1598455131
Name:DAVID, KATHERINE ELAINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELAINE
Last Name:DAVID
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 1:535 MINORS DR
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-9413
Mailing Address - Country:US
Mailing Address - Phone:414-758-3760
Mailing Address - Fax:
Practice Address - Street 1:4633 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-4220
Practice Address - Country:US
Practice Address - Phone:262-652-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7331-226101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional