Provider Demographics
NPI:1275791485
Name:FORWARD CHOICES, LLC
Entity Type:Organization
Organization Name:FORWARD CHOICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:WALLNER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC, NCC
Authorized Official - Phone:414-442-1751
Mailing Address - Street 1:140 N HINE AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-4316
Mailing Address - Country:US
Mailing Address - Phone:414-442-1751
Mailing Address - Fax:414-442-1775
Practice Address - Street 1:6040 W LISBON AVE STE 103
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2116
Practice Address - Country:US
Practice Address - Phone:414-442-1751
Practice Address - Fax:414-442-1775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-26
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3935-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2785Medicaid