Healthcare Provider Details

I. General information

NPI: 1205905908
Provider Name (Legal Business Name): WISCONSIN LUTHERAN CHILD & FAMILY SERVICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 S MAIN ST SUITE 8
FOND DU LAC WI
54935-5739
US

IV. Provider business mailing address

1049 N LYNNDALE DR SUITE 1B
APPLETON WI
54914-3050
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-9798
  • Fax: 920-731-1097
Mailing address:
  • Phone: 920-731-9798
  • Fax: 920-731-1097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. LINDA M RANGEL
Title or Position: INSURANCE PROVIDER COORDINATOR
Credential:
Phone: 262-345-5533