Provider Demographics
NPI:1821312059
Name:AUTISM INTERVENTION MILWAUKEE
Entity Type:Organization
Organization Name:AUTISM INTERVENTION MILWAUKEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:BRODERICK
Authorized Official - Last Name:WOODY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:414-256-0077
Mailing Address - Street 1:2645 N MAYFAIR RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1304
Mailing Address - Country:US
Mailing Address - Phone:414-256-0077
Mailing Address - Fax:414-256-0090
Practice Address - Street 1:2645 N MAYFAIR RD
Practice Address - Street 2:SUITE 250
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1304
Practice Address - Country:US
Practice Address - Phone:414-256-0077
Practice Address - Fax:414-256-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2041-057251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health