Healthcare Provider Details

I. General information

NPI: 1992106595
Provider Name (Legal Business Name): WADE KOSKI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2014
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4402 S 68TH ST SUITE #100
GREENFIELD WI
53220-3479
US

IV. Provider business mailing address

4402 S 68TH ST SUITE #100
GREENFIELD WI
53220-3479
US

V. Phone/Fax

Practice location:
  • Phone: 414-467-2477
  • Fax: 414-321-0552
Mailing address:
  • Phone: 414-467-2477
  • Fax: 414-321-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. WADE KOSKI
Title or Position: MEMBER
Credential: LCSW
Phone: 414-467-2477