Provider Demographics
NPI:1437325032
Name:EXODUS FAMILY SERVICES
Entity Type:Organization
Organization Name:EXODUS FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:414-550-9646
Mailing Address - Street 1:2556 N SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-2948
Mailing Address - Country:US
Mailing Address - Phone:414-550-9646
Mailing Address - Fax:
Practice Address - Street 1:3353 N MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1455
Practice Address - Country:US
Practice Address - Phone:414-550-9646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3084-123251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39581200Medicaid