Basic Information
| Provider Information | |||||||||
| NPI: | 1457674004 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA CROSSE CENTER FOR CHILDREN AND FAMILIES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | W5927 HILLCREST DR | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546018451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087889941 | ||||||||
| FaxNumber: | 6087850002 | ||||||||
| Practice Location | |||||||||
| Address1: | 2920 EAST AVE S | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546018231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087889941 | ||||||||
| FaxNumber: | 6087850002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2010 | ||||||||
| LastUpdateDate: | 03/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | ZIRKEL | ||||||||
| AuthorizedOfficialFirstName: | KIP | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 6087889941 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 781 | WI | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 39018600 | 05 | WI | MEDICAID |