Provider Demographics
NPI:1871104315
Name:KOVNESKY, KELLY J (LPC-IT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:KOVNESKY
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:J
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC-IT
Mailing Address - Street 1:810 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-1140
Mailing Address - Country:US
Mailing Address - Phone:920-388-7030
Mailing Address - Fax:920-388-7124
Practice Address - Street 1:810 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1140
Practice Address - Country:US
Practice Address - Phone:920-388-7030
Practice Address - Fax:920-388-7124
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4534-226104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker