MEDICARE: WILLOWGLEN ACADEMY, INC.

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	251C00000X	Developmentally Disabled Services Day Training Agency	2366	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2366	OTHER	WI	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881745776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOWGLEN ACADEMY, INC.

Provider Business Mailing Address
First Line	:	1744 N FARWELL AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-1806
Country	:	US
Telephone Number	:	414-225-4460
Fax Number	:	414-225-4469

Provider Business Practice Location Address
First Line	:	3903 W LISBON AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1835
Country	:	US
Telephone Number	:	414-342-2060
Fax Number	:	414-342-3663

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	MR. LEONARD F DZIUBLA
Credential	:	LCSW
Telephone Number	:	414-225-4460

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	08/22/2020

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