Provider Demographics
NPI:1174152318
Name:KOTTKE, ROCHELLE A (LCSW)
Entity type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:A
Last Name:KOTTKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ROCHELLE
Other - Middle Name:A
Other - Last Name:ROBAIDEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:320 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5918
Mailing Address - Country:US
Mailing Address - Phone:920-832-1624
Mailing Address - Fax:920-832-2185
Practice Address - Street 1:320 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5918
Practice Address - Country:US
Practice Address - Phone:920-832-5270
Practice Address - Fax:920-832-4767
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI128043104100000X
WI98371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100100274Medicaid