Basic Information
| Provider Information | |||||||||
| NPI: | 1740355395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERNST | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 721 AMERICAN AVE | ||||||||
| Address2: | SUITE 501 | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531885071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629282396 | ||||||||
| FaxNumber: | 2625441213 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 AMERICAN AVE | ||||||||
| Address2: | SUITE 501 | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531885071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629282396 | ||||||||
| FaxNumber: | 2625441213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 1549-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 40989900 | 05 | WI | MEDICAID |