Provider Demographics
NPI:1336269422
Name:BUCKWHEAT, KENNETH L (CSAC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:BUCKWHEAT
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 2ND AVE W
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3133
Mailing Address - Country:US
Mailing Address - Phone:715-682-3916
Mailing Address - Fax:
Practice Address - Street 1:502 MAIN ST W STE 305
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-1512
Practice Address - Country:US
Practice Address - Phone:715-682-5207
Practice Address - Fax:715-682-5209
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11955-134101YA0400X
WI1251-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39330400Medicaid