Provider Demographics
NPI:1750511952
Name:KOHLS WANKEY, TINA (LCSW)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:KOHLS WANKEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:M
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1855 S KOELLER ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-6214
Mailing Address - Country:US
Mailing Address - Phone:920-223-7350
Mailing Address - Fax:
Practice Address - Street 1:1855 S KOELLER ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-6214
Practice Address - Country:US
Practice Address - Phone:920-223-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7541-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical