Provider Demographics
NPI:1881778884
Name:KUYKENDALL, DAVID A (LCSW CADC III CCS)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:KUYKENDALL
Suffix:
Gender:M
Credentials:LCSW CADC III CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N 5584 CTY HWY A
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551
Mailing Address - Country:US
Mailing Address - Phone:608-825-6711
Mailing Address - Fax:608-834-6499
Practice Address - Street 1:1500 W MAIN ST
Practice Address - Street 2:SUITE 300 PHOENIX COUNSELING
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590
Practice Address - Country:US
Practice Address - Phone:608-825-6711
Practice Address - Fax:608-834-6499
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6451231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI645123OtherSTATE OF WI
WI220OtherSTATE OF WI
WI39517000Medicaid