Provider Demographics
NPI:1316097843
Name:KOTKIN, MICHAEL S (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:KOTKIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9415 W. FOREST HOME AVE. SUITE 104
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130
Mailing Address - Country:US
Mailing Address - Phone:414-858-9191
Mailing Address - Fax:414-858-9192
Practice Address - Street 1:9415 W. FOREST HOME AVE. SUITE 104
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130
Practice Address - Country:US
Practice Address - Phone:414-858-9191
Practice Address - Fax:414-858-9192
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI964103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39095900Medicaid
WI39095900Medicaid