Basic Information
Provider Information | |||||||||
NPI: | 1477100055 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WISCONSIN LUTHERAN CHILD & FAMILY SERVICE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | W175N11120 STONEWOOD DR | ||||||||
Address2: |   | ||||||||
City: | GERMANTOWN | ||||||||
State: | WI | ||||||||
PostalCode: | 530224799 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004381772 | ||||||||
FaxNumber: | 2623455562 | ||||||||
Practice Location | |||||||||
Address1: | 1300 WESTERN AVE | ||||||||
Address2: |   | ||||||||
City: | WATERTOWN | ||||||||
State: | WI | ||||||||
PostalCode: | 530944814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004381772 | ||||||||
FaxNumber: | 2623455562 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2019 | ||||||||
LastUpdateDate: | 08/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RANGEL | ||||||||
AuthorizedOfficialFirstName: | LINDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INSURANCE COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 2623455533 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YS0200X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | School |
No ID Information.