Provider Demographics
NPI:1043661036
Name:WISCONSIN LUTHERAN CHILD & FAMILY SERVICE
Entity Type:Organization
Organization Name:WISCONSIN LUTHERAN CHILD & FAMILY SERVICE
Other - Org Name:CHRISTIAN FAMILY COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KLUG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-685-9522
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:ATTN LINDA R
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:800-438-1772
Mailing Address - Fax:262-293-9737
Practice Address - Street 1:5300 N MEADE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8383
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-293-9737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-30
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42171800Medicaid