Provider Demographics
NPI:1407370398
Name:TOMBOLO, LLC
Entity Type:Organization
Organization Name:TOMBOLO, LLC
Other - Org Name:CONNECTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOTHERAPIST/CHILD SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GENIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:414-708-5988
Mailing Address - Street 1:12545 W BURLEIGH RD STE 10
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-3101
Mailing Address - Country:US
Mailing Address - Phone:414-708-5988
Mailing Address - Fax:
Practice Address - Street 1:12545 W. BURLEIGH RD.
Practice Address - Street 2:SUITE 10
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005
Practice Address - Country:US
Practice Address - Phone:414-708-5988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7050-123261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health