Provider Demographics
NPI:1215751664
Name:MUIR, KATHLEEN (MT-BC, SAC-IT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MUIR
Suffix:
Gender:
Credentials:MT-BC, SAC-IT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3276 N 50TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-3212
Mailing Address - Country:US
Mailing Address - Phone:843-810-0366
Mailing Address - Fax:
Practice Address - Street 1:N19W24101 RIVERWOOD DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1109
Practice Address - Country:US
Practice Address - Phone:262-444-0601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13256225A00000X
WI20558-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Multi-Specialty