Healthcare Provider Details

I. General information

NPI: 1407370398
Provider Name (Legal Business Name): TOMBOLO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12545 W. BURLEIGH RD. SUITE 10
BROOKFIELD WI
53005
US

IV. Provider business mailing address

12545 W BURLEIGH RD STE 10
BROOKFIELD WI
53005-3101
US

V. Phone/Fax

Practice location:
  • Phone: 414-708-5988
  • Fax:
Mailing address:
  • Phone: 414-708-5988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number7050-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number7050-123
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number7050-123
License Number StateWI

VIII. Authorized Official

Name: MS. RENEE L. GENIN
Title or Position: PSYCHOTHERAPIST/CHILD SPECIALIST
Credential: LCSW
Phone: 414-708-5988