Provider Demographics
NPI:1801062328
Name:AUSSE, KIM MARIE (COTA)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MARIE
Last Name:AUSSE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 WASHIHGTON ROAD
Mailing Address - Street 2:WASHINGTON MANOR
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144
Mailing Address - Country:US
Mailing Address - Phone:262-658-4039
Mailing Address - Fax:
Practice Address - Street 1:3100 WASHIHGTON ROAD
Practice Address - Street 2:WASHINGTON MANOR
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144
Practice Address - Country:US
Practice Address - Phone:262-658-4039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1138-027171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40867200Medicaid