Provider Demographics
NPI:1598082729
Name:WILLOWGLEN ACADEMY-WISCONSIN, INC.
Entity Type:Organization
Organization Name:WILLOWGLEN ACADEMY-WISCONSIN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:A
Authorized Official - Last Name:LUCEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, RN
Authorized Official - Phone:414-527-6970
Mailing Address - Street 1:5151 W SILVER SPRING DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-3300
Mailing Address - Country:US
Mailing Address - Phone:414-527-6970
Mailing Address - Fax:414-527-6941
Practice Address - Street 1:5151 W SILVER SPRING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-3300
Practice Address - Country:US
Practice Address - Phone:414-527-6970
Practice Address - Fax:414-527-6941
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX CARE SYSTEMS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67227-30251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health