Provider Demographics
NPI:1962826941
Name:KLYSEN, JOANNE M
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:M
Last Name:KLYSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOANNE
Other - Middle Name:M
Other - Last Name:SALM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1061 W MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-1858
Mailing Address - Country:US
Mailing Address - Phone:920-437-8256
Mailing Address - Fax:920-437-1188
Practice Address - Street 1:1061 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-1858
Practice Address - Country:US
Practice Address - Phone:920-437-8256
Practice Address - Fax:920-437-1188
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6031-125101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6031-125OtherWISCONSIN DEPT OF SAFETY AND PROFESSIONAL SERVICES