Basic Information
| Provider Information | |||||||||
| NPI: | 1952310625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANDSTRA | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BANDSTRA | ||||||||
| OtherFirstName: | KATHY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 3 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146476326 | ||||||||
| FaxNumber: | 4146718860 | ||||||||
| Practice Location | |||||||||
| Address1: | 10400 75TH ST | ||||||||
| Address2: | #307 | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531428323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629486770 | ||||||||
| FaxNumber: | 2629486788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6867-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 640-124 | WI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.