Provider Demographics
NPI:1679959654
Name:KIMMEL, JUSTINA (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:JUSTINA
Middle Name:
Last Name:KIMMEL
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:JUSTINA
Other - Middle Name:
Other - Last Name:OLRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:717 SOUTH BLVD STE 9
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-3139
Mailing Address - Country:US
Mailing Address - Phone:608-630-1519
Mailing Address - Fax:
Practice Address - Street 1:717 SOUTH BLVD STE 9
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-3139
Practice Address - Country:US
Practice Address - Phone:608-630-1519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI129537-121104100000X
WI88011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker