Provider Demographics
NPI:1871073437
Name:KANITZ, REBECCA LYNN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:KANITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 N. HOLTON STREET
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212
Mailing Address - Country:US
Mailing Address - Phone:414-964-2565
Mailing Address - Fax:414-964-0102
Practice Address - Street 1:4200 N. HOLTON ST.
Practice Address - Street 2:SUITE 400
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-964-2565
Practice Address - Fax:414-964-0102
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI81131231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical