Provider Demographics
NPI:1497029904
Name:WIS. LUTHERAN CHILD & FAMILY SERVICES
Entity Type:Organization
Organization Name:WIS. LUTHERAN CHILD & FAMILY SERVICES
Other - Org Name:CHRISTIAN FAMILY COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:NOMMENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, CEAP
Authorized Official - Phone:262-345-5560
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:262-345-5560
Mailing Address - Fax:262-345-5562
Practice Address - Street 1:2345 N 25TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-1003
Practice Address - Country:US
Practice Address - Phone:262-345-5560
Practice Address - Fax:262-345-5562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7143-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39798400Medicaid
WI000784585Medicare PIN