Basic Information
| Provider Information | |||||||||
| NPI: | 1598416240 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDERWYST | ||||||||
| FirstName: | KALEENA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC-IT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15735 W US HIGHWAY 63 | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548436475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
| FaxNumber: | 7159345554 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 SWEDE AVE | ||||||||
| Address2: | |||||||||
| City: | TURTLE LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548890000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7159862599 | ||||||||
| FaxNumber: | 7159862521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2022 | ||||||||
| LastUpdateDate: | 01/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5197 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.