Healthcare Provider Details

I. General information

NPI: 1336214543
Provider Name (Legal Business Name): INTERCONNECTIONS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 60TH ST
KENOSHA WI
53140-4041
US

IV. Provider business mailing address

920 60TH ST
KENOSHA WI
53140-4041
US

V. Phone/Fax

Practice location:
  • Phone: 262-654-5333
  • Fax: 262-654-7818
Mailing address:
  • Phone: 262-654-5333
  • Fax: 262-654-7818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1440
License Number StateWI

VIII. Authorized Official

Name: SARAH NICHOLS
Title or Position: CO-DIRECTOR
Credential: LCSW
Phone: 262-654-5333