Provider Demographics
NPI:1174986376
Name:KETTLE MORAINE BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:KETTLE MORAINE BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CATLETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, LPC, MA, MED
Authorized Official - Phone:262-745-0368
Mailing Address - Street 1:PO BOX 732
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-0732
Mailing Address - Country:US
Mailing Address - Phone:262-745-0368
Mailing Address - Fax:
Practice Address - Street 1:N158 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:WI
Practice Address - Zip Code:53156-9789
Practice Address - Country:US
Practice Address - Phone:262-745-0368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health