Provider Demographics
NPI:1053320952
Name:CHARNIAK, KIM S (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:S
Last Name:CHARNIAK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N MAIN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-5262
Mailing Address - Country:US
Mailing Address - Phone:203-851-4209
Mailing Address - Fax:866-327-3295
Practice Address - Street 1:100 N MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-5262
Practice Address - Country:US
Practice Address - Phone:920-385-1420
Practice Address - Fax:866-327-3295
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6940-1231041C0700X
WI6940104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41001800Medicaid