Basic Information
| Provider Information | |||||||||
| NPI: | 1629723754 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WISCONSIN LUTHERAN CHILD & FAMILY SERVICE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | W175N11120 STONEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530224799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8886859522 | ||||||||
| FaxNumber: | 2623455531 | ||||||||
| Practice Location | |||||||||
| Address1: | 5051 MCCARGY ROAD | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 58603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8886859522 | ||||||||
| FaxNumber: | 2623455531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2022 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | SEMMANN | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
| AuthorizedOfficialMiddleName: | LESLIE | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2623455527 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.