Provider Demographics
NPI:1073780961
Name:CENTER FOR LIFE & LOSS INTEGRATION
Entity Type:Organization
Organization Name:CENTER FOR LIFE & LOSS INTEGRATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:F
Authorized Official - Last Name:KOEPPL
Authorized Official - Suffix:
Authorized Official - Credentials:ACSW CICSW
Authorized Official - Phone:608-258-7771
Mailing Address - Street 1:4123 MONONA DR
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-1661
Mailing Address - Country:US
Mailing Address - Phone:608-258-7771
Mailing Address - Fax:608-832-6486
Practice Address - Street 1:4123 MONONA DR
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-1661
Practice Address - Country:US
Practice Address - Phone:608-258-7771
Practice Address - Fax:608-832-6486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-11
Last Update Date:2008-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1842123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42245700Medicaid
WI42245700Medicaid