Provider Demographics
NPI:1336206671
Name:MAHNKE, KURT L (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KURT
Middle Name:L
Last Name:MAHNKE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 E ENTERPRISE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7889
Mailing Address - Country:US
Mailing Address - Phone:920-729-6780
Mailing Address - Fax:920-560-4501
Practice Address - Street 1:1477 KENWOOD CTR
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1160
Practice Address - Country:US
Practice Address - Phone:920-729-6780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI252-125101YP2500X
WI892-1231041C0700X
WI122-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43701400Medicaid