Provider Demographics
NPI:1740334770
Name:HORN, KENNAN F (MSW,CICSW)
Entity type:Individual
Prefix:
First Name:KENNAN
Middle Name:F
Last Name:HORN
Suffix:
Gender:M
Credentials:MSW,CICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 WILLARD DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5204
Mailing Address - Country:US
Mailing Address - Phone:920-497-0788
Mailing Address - Fax:
Practice Address - Street 1:840 WILLARD DR
Practice Address - Street 2:SUITE 201
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5204
Practice Address - Country:US
Practice Address - Phone:920-497-0788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1557-123106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1740334770Medicare NSC