Provider Demographics
NPI:1336264829
Name:CHILD, MARRIAGE & FAMILY THERAPY CLINIC
Entity Type:Organization
Organization Name:CHILD, MARRIAGE & FAMILY THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON VISOR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:262-886-8702
Mailing Address - Street 1:6939 MARINER DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-3938
Mailing Address - Country:US
Mailing Address - Phone:262-886-8702
Mailing Address - Fax:262-886-8714
Practice Address - Street 1:6939 MARINER DR
Practice Address - Street 2:SUITE C
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-3938
Practice Address - Country:US
Practice Address - Phone:262-886-8702
Practice Address - Fax:262-886-8714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1035-132101YA0400X
WI369-125101YP2500X
WI947-125101YP2500X
WI521-126101YP2500X
WI1012-125101YP2500X
WI2254-1231041C0700X
WI2031-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty