Provider Demographics
NPI:1427134089
Name:KOHLENBERG, CARY J (MD)
Entity type:Individual
Prefix:
First Name:CARY
Middle Name:J
Last Name:KOHLENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 N GRANDVIEW BLVD
Mailing Address - Street 2:#202
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1672
Mailing Address - Country:US
Mailing Address - Phone:262-513-0700
Mailing Address - Fax:262-513-0707
Practice Address - Street 1:2717 N GRANDVIEW BLVD
Practice Address - Street 2:#202
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1672
Practice Address - Country:US
Practice Address - Phone:262-513-0700
Practice Address - Fax:262-513-0707
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI313412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31770200Medicaid
WI31770200Medicaid