Provider Demographics
| NPI: | 1144593815 |
|---|---|
| Name: | SIXTEENTH STREET COMMUNITY HEALTH CENTERS, INC. |
| Entity Type: | Organization |
| Organization Name: | SIXTEENTH STREET COMMUNITY HEALTH CENTERS, INC. |
| Other - Org Name: | SSCHC WAUKESHA CLINIC |
| Other - Org Type: | Other Name |
| Authorized Official - Title/Position: | CFO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | MARIA CECILIA |
| Authorized Official - Middle Name: | S |
| Authorized Official - Last Name: | TAYLOR |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 414-803-6395 |
| Mailing Address - Street 1: | PO BOX 778789 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | CHICAGO |
| Mailing Address - State: | IL |
| Mailing Address - Zip Code: | 60677-8789 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 414-672-1353 |
| Mailing Address - Fax: | 262-408-5094 |
| Practice Address - Street 1: | 309 E NORTH ST |
| Practice Address - Street 2: | |
| Practice Address - City: | WAUKESHA |
| Practice Address - State: | WI |
| Practice Address - Zip Code: | 53188-3718 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 262-408-2530 |
| Practice Address - Fax: | 262-408-5094 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2012-02-10 |
| Last Update Date: | 2023-05-16 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 101Y00000X, 103T00000X, 104100000X, 207Q00000X, 207R00000X, 207V00000X, 208000000X, 225100000X, 261QM0801X, 261QM0855X, 261QM1300X, 363A00000X, 363L00000X, 367A00000X | ||
| WI | 1507-800 | 261QF0400X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | |
| No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
| No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | |
| No | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| WI | 1144593815 | Medicaid | |
| 521847 | Medicare Oscar/Certification |
