Provider Demographics
NPI:1427271147
Name:HERBISON KISTING, KATHLEEN M (CSAC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:HERBISON KISTING
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2834 22ND ST
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-9752
Mailing Address - Country:US
Mailing Address - Phone:715-234-9833
Mailing Address - Fax:
Practice Address - Street 1:100 POLK COUNTY PLZ
Practice Address - Street 2:SUITE 50
Practice Address - City:BALSAM LAKE
Practice Address - State:WI
Practice Address - Zip Code:54810-9071
Practice Address - Country:US
Practice Address - Phone:715-485-8463
Practice Address - Fax:715-485-8490
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI775 132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39345700Medicaid
WI663731021639OtherPREFERREDONE INSURANCE
WI372795OtherMHN HMC INSURANCE