Provider Demographics
NPI:1427088954
Name:KAMINSKI, ROGER S (PSYD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:S
Last Name:KAMINSKI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 E NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2906
Mailing Address - Country:US
Mailing Address - Phone:414-298-6739
Mailing Address - Fax:
Practice Address - Street 1:2025 E NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-2906
Practice Address - Country:US
Practice Address - Phone:414-298-6739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1486-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39122900Medicaid