Provider Demographics
NPI:1780981548
Name:WISCONSIN LUTHERAN CHILD & FAMILY SERVICE, INC
Entity type:Organization
Organization Name:WISCONSIN LUTHERAN CHILD & FAMILY SERVICE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE PROVIDER COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-345-5533
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:262-345-5560
Mailing Address - Fax:262-345-5562
Practice Address - Street 1:3601 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-4129
Practice Address - Country:US
Practice Address - Phone:262-345-5560
Practice Address - Fax:262-345-5562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12699-131101YA0400X
WI4123-125101YP2500X
WI2282-125101YP2500X
WI2163-57103TC1900X
WI1967-1231041C0700X
WI6155-1231041C0700X
WI7143-1231041C0700X
WI4538-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42223600Medicaid
WI000084585Medicare PIN