Provider Demographics
NPI:1619147048
Name:WILLOWGLEN ACADEMY INC
Entity Type:Organization
Organization Name:WILLOWGLEN ACADEMY INC
Other - Org Name:WILLOWGLEN ACADEMY OUTPATIENT CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF OUTPATIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:414-445-9180
Mailing Address - Street 1:4065 N 35TH ST
Mailing Address - Street 2:SUITE N100
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1705
Mailing Address - Country:US
Mailing Address - Phone:414-445-9180
Mailing Address - Fax:414-445-5995
Practice Address - Street 1:4065 N 35TH ST
Practice Address - Street 2:SUITE N100
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1705
Practice Address - Country:US
Practice Address - Phone:414-445-9180
Practice Address - Fax:414-445-5995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2004261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42167200Medicaid