Basic Information
| Provider Information | |||||||||
| NPI: | 1639343320 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINTA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAINT AEMLILIAN | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8901 W. CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532221706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144655751 | ||||||||
| FaxNumber: | 4144632770 | ||||||||
| Practice Location | |||||||||
| Address1: | 8901 W. CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532221706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144655751 | ||||||||
| FaxNumber: | 4144632770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 05/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | PAHLAVAN | ||||||||
| AuthorizedOfficialFirstName: | JODY | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF CLINICAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4144655751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PSY.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Mental Health | 261QR0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QM0801X | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 100078122 | 05 | WI | MEDICAID | 43016900 | 05 | WI | MEDICAID |