Provider Demographics
NPI:1639343320
Name:WELLPOINT CARE NETWORK
Entity Type:Organization
Organization Name:WELLPOINT CARE NETWORK
Other - Org Name:SAINTA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT OF CLINICAL SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:JODY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PAHLAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:414-463-1880
Mailing Address - Street 1:8901 W. CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1706
Mailing Address - Country:US
Mailing Address - Phone:414-465-5751
Mailing Address - Fax:414-463-2770
Practice Address - Street 1:8901 W. CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1706
Practice Address - Country:US
Practice Address - Phone:414-465-5751
Practice Address - Fax:414-463-2770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XM0800X, 261QR0400X
WI261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental HealthGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100078122Medicaid
WI43016900Medicaid