Basic Information
| Provider Information | |||||||||
| NPI: | 1477822534 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WISCONSIN INDEPENDENT LIVING SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2821 N 4TH ST | ||||||||
| Address2: | STE 516 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532122362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142636000 | ||||||||
| FaxNumber: | 4143322523 | ||||||||
| Practice Location | |||||||||
| Address1: | 2821 N 4TH ST | ||||||||
| Address2: | STE 516 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532122362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142636000 | ||||||||
| FaxNumber: | 4143322523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2011 | ||||||||
| LastUpdateDate: | 01/03/2013 | ||||||||
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| AuthorizedOfficialLastName: | SAMPTON FOSSIE | ||||||||
| AuthorizedOfficialFirstName: | SHELIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4142636000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.