Basic Information
| Provider Information | |||||||||
| NPI: | 1942362066 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF MILWAUKEE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MILWAUKEE COUNTY BEHAVIORAL HEALTH PSYCHOLOGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9455 W WATERTOWN PLANK RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142576995 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9455 W WATERTOWN PLANK RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142576995 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OLESZAK | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4142577088 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 000000812 | 01 | WI | MEDICARE PTAN | OTHER | 43551200 | 05 | WI | MEDICAID |