Provider Demographics
NPI:1336915370
Name:AUTISM SOCIETY OF SOUTHEASTERN WISCONSIN
Entity Type:Organization
Organization Name:AUTISM SOCIETY OF SOUTHEASTERN WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-988-1261
Mailing Address - Street 1:3720 N 124TH ST STE O
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-2100
Mailing Address - Country:US
Mailing Address - Phone:414-988-1260
Mailing Address - Fax:
Practice Address - Street 1:3720 N 124TH ST STE O
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-2100
Practice Address - Country:US
Practice Address - Phone:414-988-1260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-30
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable