Provider Demographics
NPI:1881745776
Name:WILLOWGLEN ACADEMY, INC.
Entity type:Organization
Organization Name:WILLOWGLEN ACADEMY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:DZIUBLA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:414-225-4460
Mailing Address - Street 1:1744 N FARWELL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-1806
Mailing Address - Country:US
Mailing Address - Phone:414-225-4460
Mailing Address - Fax:414-225-4469
Practice Address - Street 1:3903 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1835
Practice Address - Country:US
Practice Address - Phone:414-342-2060
Practice Address - Fax:414-342-3663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2366251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2366OtherSTATE LICENSE
WI43003300Medicaid