Provider Demographics
NPI:1972855914
Name:KIRBY, SAMUEL H (SAC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:H
Last Name:KIRBY
Suffix:
Gender:M
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3113 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-4330
Mailing Address - Country:US
Mailing Address - Phone:608-242-0220
Mailing Address - Fax:608-242-1166
Practice Address - Street 1:3113 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4330
Practice Address - Country:US
Practice Address - Phone:608-242-0220
Practice Address - Fax:608-242-1166
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15769-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)