Provider Demographics
NPI:1063902450
Name:KUENNEN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KUENNEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10450 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-2911
Mailing Address - Country:US
Mailing Address - Phone:262-657-7453
Mailing Address - Fax:262-671-5013
Practice Address - Street 1:10450 72ND AVE
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-2911
Practice Address - Country:US
Practice Address - Phone:262-657-7453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100054165Medicaid