Provider Demographics
NPI:1154143527
Name:KACZMAREK, KATHERINE LEIGH (LCP-IT)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LEIGH
Last Name:KACZMAREK
Suffix:
Gender:F
Credentials:LCP-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2912
Mailing Address - Country:US
Mailing Address - Phone:262-412-5562
Mailing Address - Fax:
Practice Address - Street 1:3818 60TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-2767
Practice Address - Country:US
Practice Address - Phone:262-842-7012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7798-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health