Basic Information
Provider Information | |||||||||
NPI: | 1063964591 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WISCONSIN LUTHERAN CHILD & FAMILY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHRISTIAN FAMILY COUNSELING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | W175N11120 STONEWOOD DR | ||||||||
Address2: | ATTN: LINDA RANGEL | ||||||||
City: | GERMANTOWN | ||||||||
State: | WI | ||||||||
PostalCode: | 530226511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004381772 | ||||||||
FaxNumber: | 2622939737 | ||||||||
Practice Location | |||||||||
Address1: | 4200 W DOUGLAS AVE | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532093529 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004381772 | ||||||||
FaxNumber: | 2622939737 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2016 | ||||||||
LastUpdateDate: | 02/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RANGEL | ||||||||
AuthorizedOfficialFirstName: | LINDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INSURANCE COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 2623455533 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 17655-130 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 2449-226 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 42223600 | 05 | WI |   | MEDICAID |