Provider Demographics
NPI:1578023156
Name:MIDWAY CLINICAL NEUROPSYCHOLOGIC INSTITUTE AND CHILDREN'S WELLNESS FOU
Entity Type:Organization
Organization Name:MIDWAY CLINICAL NEUROPSYCHOLOGIC INSTITUTE AND CHILDREN'S WELLNESS FOU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:262-455-2919
Mailing Address - Street 1:P.O. BOX 684
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53141-0684
Mailing Address - Country:US
Mailing Address - Phone:262-455-2919
Mailing Address - Fax:262-455-2919
Practice Address - Street 1:1024 60TH STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-4099
Practice Address - Country:US
Practice Address - Phone:262-455-2919
Practice Address - Fax:262-455-2919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty