Provider Demographics
NPI:1053379792
Name:NEVILLE, KATHLEEN A (LCSW)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:A
Last Name:NEVILLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:A
Other - Last Name:FREDRICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3970 N OAKLAND AVE
Mailing Address - Street 2:502
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2265
Mailing Address - Country:US
Mailing Address - Phone:414-332-9096
Mailing Address - Fax:414-332-8596
Practice Address - Street 1:3970 N OAKLAND AVE
Practice Address - Street 2:502
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-2265
Practice Address - Country:US
Practice Address - Phone:414-332-9096
Practice Address - Fax:414-332-8596
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490107241041C0700X
WI1471231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01634461OtherBCBS
WI39253100Medicaid
WI39253100Medicaid