Basic Information
| Provider Information | |||||||||
| NPI: | 1780981548 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WISCONSIN LUTHERAN CHILD & FAMILY SERVICE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CHRISTIAN FAMILY COUNSELING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | W175N11120 STONEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530226511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623455560 | ||||||||
| FaxNumber: | 2623455562 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 N PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532124129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623455560 | ||||||||
| FaxNumber: | 2623455562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2011 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RANGEL | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE PROVIDER COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2623455533 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 12699-131 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 4123-125 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 2282-125 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103TC1900X | 2163-57 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 1041C0700X | 1967-123 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 6155-123 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 7143-123 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YP2500X | 4538-125 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 42223600 | 05 | WI | MEDICAID |