Provider Demographics
NPI:1679981328
Name:LIFE CHANGING MINISTRIES SUBSTANCE ABUSE SERVICES
Entity Type:Organization
Organization Name:LIFE CHANGING MINISTRIES SUBSTANCE ABUSE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHELSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-467-8884
Mailing Address - Street 1:1134 W NORTH AVE 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205-1333
Mailing Address - Country:US
Mailing Address - Phone:414-269-9660
Mailing Address - Fax:414-755-0698
Practice Address - Street 1:1134 W NORTH AVE 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205
Practice Address - Country:US
Practice Address - Phone:414-269-9660
Practice Address - Fax:414-755-0698
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE CHANGING MINISTRIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-25
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QM0801X
WI3045324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI52D2142323OtherFDA CLIA
WI100041767Medicaid
WI100043806Medicaid