Provider Demographics
NPI:1356555965
Name:HUMES, WILFRED A (10492132 CSAC 117391)
Entity type:Individual
Prefix:MR
First Name:WILFRED
Middle Name:A
Last Name:HUMES
Suffix:
Gender:M
Credentials:10492132 CSAC 117391
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 NORTH GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188
Mailing Address - Country:US
Mailing Address - Phone:262-549-6600
Mailing Address - Fax:262-549-6698
Practice Address - Street 1:2422 NORTH GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188
Practice Address - Country:US
Practice Address - Phone:262-549-6600
Practice Address - Fax:262-549-6698
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11739135101YA0400X
WI104921321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39398000Medicaid