Provider Demographics
NPI:1881758928
Name:KINNEY, RAY WOODSON (MS)
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:WOODSON
Last Name:KINNEY
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:W344S8780 WHITETAIL DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:WI
Mailing Address - Zip Code:53119-2318
Mailing Address - Country:US
Mailing Address - Phone:262-391-5561
Mailing Address - Fax:262-542-0823
Practice Address - Street 1:741 N GRAND AVE
Practice Address - Street 2:#302
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4820
Practice Address - Country:US
Practice Address - Phone:262-542-3255
Practice Address - Fax:262-542-0823
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4034-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4034-123OtherLICENSED CLINICAL SOCIAL