Provider Demographics
NPI:1972942175
Name:LEWIS, KIMBERLY (LCSW, CSAC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S. KENSINGTON DR. STE. 400
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-4186
Mailing Address - Country:US
Mailing Address - Phone:920-659-0634
Mailing Address - Fax:920-239-6003
Practice Address - Street 1:140 W MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:WINNECONNE
Practice Address - State:WI
Practice Address - Zip Code:54986-9409
Practice Address - Country:US
Practice Address - Phone:920-460-9814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14548-132101YA0400X
WI7377-1231041C0700X, 104100000X
WI73771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
100194005OtherFORWARD HEALTH
WI1972942175Medicaid
WI100194005Medicaid