Basic Information
| Provider Information | |||||||||
| NPI: | 1639520612 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WISCONSIN LUTHERAN CHILD & FAMILY SERVICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHRISTIAN FAMILY COUNSELING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | W175N11120 STONEWOOD DR | ||||||||
| Address2: | ATTN: LINDA RANGEL | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530226511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004381772 | ||||||||
| FaxNumber: | 2622939737 | ||||||||
| Practice Location | |||||||||
| Address1: | 3399 DIVISION RD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530379707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004381772 | ||||||||
| FaxNumber: | 2622939737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2016 | ||||||||
| LastUpdateDate: | 06/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | KLUG | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8886859522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 42223600 | 05 | WI | MEDICAID |