Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 15891-132 | WI |
N | 104100000X | Social Worker | 129568-121 | WI |
NPI | 1003208505 |
---|---|
Provider Name | Mrs. Kathleen Stockman |
First Address | Green Bay, WI 54303-3865 |
Second Address | Sturgeon Bay, WI 54235-2225 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/02/2015 |
Last Update Date | 20/02/2015 |