Provider Demographics
NPI:1578730412
Name:ST. CHARLES YOUTH & FAMILY SERVICES
Entity Type:Organization
Organization Name:ST. CHARLES YOUTH & FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-476-3710
Mailing Address - Street 1:151 S 84TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1456
Mailing Address - Country:US
Mailing Address - Phone:414-476-3710
Mailing Address - Fax:414-778-5985
Practice Address - Street 1:310 TROY DR
Practice Address - Street 2:COTTAGE B
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704
Practice Address - Country:US
Practice Address - Phone:608-663-5910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1011445320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43009100Medicaid