1609043165 NPI number — ST AEMILIAN LAKESIDE INC

Table of content: (NPI 1609043165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609043165 NPI number — ST AEMILIAN LAKESIDE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST AEMILIAN LAKESIDE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609043165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8901 W CAPITOL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53222-1706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-463-1880
Provider Business Mailing Address Fax Number:
414-463-2770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8901 W CAPITOL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53222-1706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-463-1880
Provider Business Practice Location Address Fax Number:
414-463-2770
Provider Enumeration Date:
05/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KIRBY
Authorized Official First Name:
AMY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PROGRAM COORDINATOR
Authorized Official Telephone Number:
414-463-1880

Provider Taxonomy Codes

  • Taxonomy code: 253J00000X , with the licence number:  6949-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6949-123 . This is a "STATE OF WISCONSIN CLINICAL SOCIAL WORK LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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