Provider Demographics
NPI:1629636873
Name:AUTISM SOCIETY OF GREATER WISCONSIN
Entity Type:Organization
Organization Name:AUTISM SOCIETY OF GREATER WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODHAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-558-4602
Mailing Address - Street 1:1477 KENWOOD DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1160
Mailing Address - Country:US
Mailing Address - Phone:920-558-4602
Mailing Address - Fax:920-558-4611
Practice Address - Street 1:1477 KENWOOD DR STE 100
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1160
Practice Address - Country:US
Practice Address - Phone:920-558-4602
Practice Address - Fax:920-558-4611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable