MEDICARE: WESTLAKE CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	2395	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2395	OTHER	WI	OUTPAT MENTLHEALTH CLINIC

General Provider Information

NPI Number	:	1578523775
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTLAKE CLINIC, LLC

Provider Business Mailing Address
First Line	:	10533 W NATIONAL AVE
Second Line	:	SUITE 300
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-2041
Country	:	US
Telephone Number	:	414-327-5200
Fax Number	:	414-327-5400

Provider Business Practice Location Address
First Line	:	10533 W NATIONAL AVE
Second Line	:	SUITE 300
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-2041
Country	:	US
Telephone Number	:	414-327-5200
Fax Number	:	414-327-5400

Authorized Official
Title or Position	:	OWNER AND PSYCHOTHERAPIST
Name	:	MS. JESSICA JOAN SUHR
Credential	:	LCSW
Telephone Number	:	414-327-5200

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	08/22/2020

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