Provider Demographics
NPI:1689145500
Name:OCONOMOWOC DEVELOPMENTAL TRAINING CENTER OF WISCONSIN LLC
Entity Type:Organization
Organization Name:OCONOMOWOC DEVELOPMENTAL TRAINING CENTER OF WISCONSIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RAML-GLIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MSSW
Authorized Official - Phone:262-569-5510
Mailing Address - Street 1:36100 GENESEE LAKE SCHOOL
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066
Mailing Address - Country:US
Mailing Address - Phone:262-569-5510
Mailing Address - Fax:
Practice Address - Street 1:36100 GENESEE LAKE SCHOOL
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066
Practice Address - Country:US
Practice Address - Phone:262-569-5510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OCONOMOWOC DEVELOPMENTAL TRAINING CENTER OF WISCONSIN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children