Provider Demographics
NPI:1235128356
Name:SOUTH STREET CLINIC LLC
Entity Type:Organization
Organization Name:SOUTH STREET CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:ALEXA
Authorized Official - Last Name:WESTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:262-567-7673
Mailing Address - Street 1:416 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-2755
Mailing Address - Country:US
Mailing Address - Phone:262-567-7673
Mailing Address - Fax:262-567-3097
Practice Address - Street 1:416 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-2755
Practice Address - Country:US
Practice Address - Phone:262-567-7673
Practice Address - Fax:262-567-3097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1841103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42217900Medicaid
44495Medicare ID - Type Unspecified