1306305941 NPI number — CHILDREN'S SERVICE SOCIETY OF WISCONSIN

Table of content: (NPI 1306305941)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306305941 NPI number — CHILDREN'S SERVICE SOCIETY OF WISCONSIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S SERVICE SOCIETY OF WISCONSIN
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:
BLACK RIVER FALLS PNCC
Provider Other Organization Name Type Code:
3
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:
1306305941
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9000 W WISCONSIN AVE # MS 958
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:
53226-4874
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-266-7615
Provider Business Mailing Address Fax Number:
414-266-6238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W11109 ROGERS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACK RIVER FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54615-6051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-284-3001
Provider Business Practice Location Address Fax Number:
715-284-3005
Provider Enumeration Date:
03/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
REUTEMAN
Authorized Official First Name:
SHEILA
Authorized Official Middle Name:
Authorized Official Title or Position:
SR. CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
414-266-7615

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1186 . This is a "LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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