Provider Demographics
NPI:1790115954
Name:LIFE ENHANCEMENT SUPPORTIVE SERVICES
Entity Type:Organization
Organization Name:LIFE ENHANCEMENT SUPPORTIVE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TONYETTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:BS, SACIT
Authorized Official - Phone:414-690-0672
Mailing Address - Street 1:6001 W CENTER ST STE 201
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-2154
Mailing Address - Country:US
Mailing Address - Phone:414-444-2380
Mailing Address - Fax:
Practice Address - Street 1:6001 W CENTER ST STE 201
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2154
Practice Address - Country:US
Practice Address - Phone:414-444-2380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15896-130251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12088599OtherCAQH
WI1184060998OtherNPI