Provider Demographics
NPI:1184441578
Name:SUMMERALL, JAMES KINTA
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:KINTA
Last Name:SUMMERALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 N FRATNEY ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2950
Mailing Address - Country:US
Mailing Address - Phone:414-791-4996
Mailing Address - Fax:
Practice Address - Street 1:2655 N FRATNEY ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2950
Practice Address - Country:US
Practice Address - Phone:414-791-4996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YM0800101YM0800X
WI1381-26202844101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health