Provider Demographics
NPI:1679678635
Name:KABARA, TIMOTHY (EDS, LMHP, PPSP)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:KABARA
Suffix:
Gender:M
Credentials:EDS, LMHP, PPSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 S 97TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4133
Mailing Address - Country:US
Mailing Address - Phone:262-510-4447
Mailing Address - Fax:
Practice Address - Street 1:1455 S 97TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4133
Practice Address - Country:US
Practice Address - Phone:262-510-4447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIK160000634152103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34700400Medicaid