Basic Information
| Provider Information | |||||||||
| NPI: | 1235728643 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WISCONSIN LUTHERAN CHILD & FAMILY SERVICE ,INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | W175N11120 STONEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530224799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004381772 | ||||||||
| FaxNumber: | 2622939737 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 W CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550411515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004381772 | ||||||||
| FaxNumber: | 2623455562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2021 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | RANGEL | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE COORDIANTOR | ||||||||
| AuthorizedOfficialTelephone: | 8004381772 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP2701X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
No ID Information.