Provider Demographics
NPI:1760723712
Name:RILEY, KIMBERLY JO (LMFT CSAC ICS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:RILEY
Suffix:
Gender:F
Credentials:LMFT CSAC ICS
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:J
Other - Last Name:HUTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT CSAC ICS
Mailing Address - Street 1:20 W GAILEN LN
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53563-8752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:E401 23RD ST
Practice Address - Street 2:
Practice Address - City:BRODHEAD
Practice Address - State:WI
Practice Address - Zip Code:53520-2203
Practice Address - Country:US
Practice Address - Phone:608-690-3078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15970-132101YA0400X
WI331-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)