Provider Demographics
NPI:1790030294
Name:RICH, KEVIN (CSAC-IT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:RICH
Suffix:
Gender:M
Credentials:CSAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 N 4TH ST
Mailing Address - Street 2:SUITE 139
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2362
Mailing Address - Country:US
Mailing Address - Phone:414-264-4217
Mailing Address - Fax:414-264-4218
Practice Address - Street 1:6400 INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-2452
Practice Address - Country:US
Practice Address - Phone:414-423-4100
Practice Address - Fax:414-423-4134
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16650-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)