Provider Demographics
NPI:1639317167
Name:KIDS IN TRANSITION
Entity Type:Organization
Organization Name:KIDS IN TRANSITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLEON
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:CSAC,ICS
Authorized Official - Phone:414-688-3062
Mailing Address - Street 1:6314 N 104TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-1408
Mailing Address - Country:US
Mailing Address - Phone:414-688-3062
Mailing Address - Fax:414-277-8916
Practice Address - Street 1:6314 N 104TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-1408
Practice Address - Country:US
Practice Address - Phone:414-688-3062
Practice Address - Fax:414-277-8916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10600132251S00000X
WI11828134251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39387800Medicaid