Provider Demographics
NPI:1619300217
Name:KITZBERGER, KIMBERLY JEAN (SAC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEAN
Last Name:KITZBERGER
Suffix:
Gender:F
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WISCONSIN STREET
Mailing Address - Street 2:UNIT 49
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703
Mailing Address - Country:US
Mailing Address - Phone:715-855-6181
Mailing Address - Fax:715-838-2949
Practice Address - Street 1:800 WISCONSIN STREET
Practice Address - Street 2:UNIT 49
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703
Practice Address - Country:US
Practice Address - Phone:715-855-6181
Practice Address - Fax:715-838-2949
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15758-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)