Provider Demographics
NPI:1093941262
Name:ST. CHARLES YOUTH & FAMILY SERVICES
Entity Type:Organization
Organization Name:ST. CHARLES YOUTH & FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER MENTAL HEALTH CLINI
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:HICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:414-358-4167
Mailing Address - Street 1:4757 N 76TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-4732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4757 N 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4732
Practice Address - Country:US
Practice Address - Phone:414-358-4173
Practice Address - Fax:414-358-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4296-125251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management