Provider Demographics
NPI:1992195192
Name:RUSS KINKADE, PSY.D., S.C.
Entity Type:Organization
Organization Name:RUSS KINKADE, PSY.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:KINKADE
Authorized Official - Suffix:JR
Authorized Official - Credentials:PSYD
Authorized Official - Phone:262-989-5228
Mailing Address - Street 1:S55W29307 HOLIDAY POINT DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-9026
Mailing Address - Country:US
Mailing Address - Phone:262-989-5228
Mailing Address - Fax:262-878-9285
Practice Address - Street 1:6214 WASHINGTON AVE
Practice Address - Street 2:C-10
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-3986
Practice Address - Country:US
Practice Address - Phone:262-989-5228
Practice Address - Fax:262-878-9285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1296261Q00000X
261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health