Healthcare Provider Details

I. General information

NPI: 1386504686
Provider Name (Legal Business Name): UNIVERSITY LAKE SCHOOL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2025
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4024 NAGAWICKA RD
HARTLAND WI
53029-9363
US

IV. Provider business mailing address

4024 NAGAWICKA RD
HARTLAND WI
53029-9363
US

V. Phone/Fax

Practice location:
  • Phone: 262-501-3255
  • Fax: 262-214-0157
Mailing address:
  • Phone: 262-501-3255
  • Fax: 262-214-0157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MELISSA BENSON
Title or Position: CFO
Credential:
Phone: 262-367-6011