Provider Demographics
NPI:1407933963
Name:KIRSCH, JAMES TARY (MS, LPC)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:TARY
Last Name:KIRSCH
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4469 WYANDOT TRL
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6789
Mailing Address - Country:US
Mailing Address - Phone:920-490-0991
Mailing Address - Fax:
Practice Address - Street 1:2733 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5513
Practice Address - Country:US
Practice Address - Phone:920-497-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3373-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40952000Medicaid
WI3373-125OtherLPC