Provider Demographics
NPI:1710192000
Name:TISSOT, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:TISSOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1309
Mailing Address - Country:US
Mailing Address - Phone:414-257-0233
Mailing Address - Fax:414-257-3588
Practice Address - Street 1:2600 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1309
Practice Address - Country:US
Practice Address - Phone:414-257-0233
Practice Address - Fax:414-257-3588
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4175-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health