Provider Demographics
NPI:1043727324
Name:KENEALY, KAITLYN (MA, LPC)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:KENEALY
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 S MAIN ST STE M05
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4386
Mailing Address - Country:US
Mailing Address - Phone:920-659-5414
Mailing Address - Fax:
Practice Address - Street 1:131 S MAIN ST STE M05
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4386
Practice Address - Country:US
Practice Address - Phone:920-659-5414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7577-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional