Provider Demographics
NPI:1417988973
Name:ACACIA CLINIC, INC.
Entity Type:Organization
Organization Name:ACACIA CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEIDRA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KOZLOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-871-9111
Mailing Address - Street 1:6040 W LISBON AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-2116
Mailing Address - Country:US
Mailing Address - Phone:414-871-9111
Mailing Address - Fax:414-871-9121
Practice Address - Street 1:6040 W LISBON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2116
Practice Address - Country:US
Practice Address - Phone:414-871-9111
Practice Address - Fax:414-871-9121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1066101YM0800X, 103T00000X, 103TC0700X, 103TC1900X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42167800Medicaid