Basic Information
| Provider Information | |||||||||
| NPI: | 1326154378 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORNERSTONE COUNSELING SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4811 S 76TH ST | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532204364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148170442 | ||||||||
| FaxNumber: | 4148170442 | ||||||||
| Practice Location | |||||||||
| Address1: | 4811 S 76TH ST | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532204364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148170442 | ||||||||
| FaxNumber: | 4148170442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 08/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | JENKS | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | A.O.D.A. COUNSLER | ||||||||
| AuthorizedOfficialTelephone: | 2625423255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | C.A.D.C.III | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 684 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 39356400 | 05 | WI | MEDICAID |