Provider Demographics
NPI:1669648960
Name:ST. CHARLES YOUTH & FAMILY SERVICES
Entity Type:Organization
Organization Name:ST. CHARLES YOUTH & FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-476-3710
Mailing Address - Street 1:151 S 84TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1456
Mailing Address - Country:US
Mailing Address - Phone:414-476-3710
Mailing Address - Fax:414-778-5985
Practice Address - Street 1:9501 W WATERTOWN PLANK RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3552
Practice Address - Country:US
Practice Address - Phone:414-476-3710
Practice Address - Fax:414-778-5985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1005239320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43018000Medicaid