Basic Information
| Provider Information | |||||||||
| NPI: | 1548434848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S SERVICE SOCIETY OF WISCONSIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8800 WASHINGTON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534063701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626333591 | ||||||||
| FaxNumber: | 2626332619 | ||||||||
| Practice Location | |||||||||
| Address1: | 8800 WASHINGTON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534063701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626333591 | ||||||||
| FaxNumber: | 2626332619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2008 | ||||||||
| LastUpdateDate: | 03/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | OERTER | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM DIRECTOR OF COUNSELING | ||||||||
| AuthorizedOfficialTelephone: | 4142662912 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 42136500 | 05 | WI | MEDICAID |