Provider Demographics
NPI:1376718320
Name:ST. CHARLES
Entity Type:Organization
Organization Name:ST. CHARLES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUBSTANCE ABUSE COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:ANNA
Authorized Official - Last Name:DIBB
Authorized Official - Suffix:
Authorized Official - Credentials:15361131
Authorized Official - Phone:414-358-5381
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:414-358-4145
Mailing Address - Fax:414-358-5002
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:414-358-4145
Practice Address - Fax:414-358-5002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15361131251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3918300Medicaid