Provider Demographics
NPI:1679725352
Name:PATHWAY ECLINIC SC
Entity Type:Organization
Organization Name:PATHWAY ECLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CORNELLA- CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-727-4455
Mailing Address - Street 1:2300 N MAYFAIR RD
Mailing Address - Street 2:SUITE 425
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1505
Mailing Address - Country:US
Mailing Address - Phone:414-727-4455
Mailing Address - Fax:414-727-4690
Practice Address - Street 1:2300 N MAYFAIR RD
Practice Address - Street 2:SUITE 425
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1505
Practice Address - Country:US
Practice Address - Phone:414-727-4455
Practice Address - Fax:414-727-4690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2605101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty