Provider Demographics
NPI:1396037511
Name:EASTER SEALS SOUTHEAST WISCONSIN
Entity Type:Organization
Organization Name:EASTER SEALS SOUTHEAST WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JUROWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:262-581-5394
Mailing Address - Street 1:3090 N 53RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1617
Mailing Address - Country:US
Mailing Address - Phone:414-449-4444
Mailing Address - Fax:
Practice Address - Street 1:3090 N 53RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1617
Practice Address - Country:US
Practice Address - Phone:414-449-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTER SEALS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIBCBA 103K00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41209100Medicaid
WI000030805Medicare UPIN