Provider Demographics
NPI:1891711222
Name:NEERAJ AGRAWAL CLINIC LTD
Entity Type:Organization
Organization Name:NEERAJ AGRAWAL CLINIC LTD
Other - Org Name:NEERAJ AGRAWAL
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR & PSYCHOTHERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NEERAJ
Authorized Official - Middle Name:B
Authorized Official - Last Name:AGRAWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, SAC, LPC
Authorized Official - Phone:414-628-3457
Mailing Address - Street 1:11450 N CONCORD CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-4387
Mailing Address - Country:US
Mailing Address - Phone:414-628-3457
Mailing Address - Fax:262-252-4874
Practice Address - Street 1:7332 W STATE ST # LL
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2766
Practice Address - Country:US
Practice Address - Phone:414-628-3457
Practice Address - Fax:262-252-4874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11544101YA0400X
WI2847125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43553100Medicaid
WI242647OtherVALUEOPTIONS