Provider Demographics
NPI:1053760140
Name:KJELL, ATHENA
Entity type:Individual
Prefix:MRS
First Name:ATHENA
Middle Name:
Last Name:KJELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ATHENA
Other - Middle Name:
Other - Last Name:MROTEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2607 N GRANDVIEW BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1690
Mailing Address - Country:US
Mailing Address - Phone:262-313-8339
Mailing Address - Fax:
Practice Address - Street 1:2607 N GRANDVIEW BLVD STE 110
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1690
Practice Address - Country:US
Practice Address - Phone:262-313-8339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YA0400X
WI6811-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)