Basic Information
| Provider Information | |||||||||
| NPI: | 1265572077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLUSKEY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | KAHN | ||||||||
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| Credential: | MS LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1218 N 4TH ST | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | TOMAHAWK | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544872135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152242100 | ||||||||
| FaxNumber: | 7152242106 | ||||||||
| Practice Location | |||||||||
| Address1: | 1218 N 4TH ST | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | TOMAHAWK | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544872135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152242100 | ||||||||
| FaxNumber: | 7152242106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 10/27/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 2870125 | WI | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 43561300 | 05 | WI | MEDICAID |