Healthcare Provider Details

I. General information

NPI: 1699155648
Provider Name (Legal Business Name): CENTER FOR LANGUAGE ACQUISITION AND SOCIAL SKILLS INTERVENTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8239 W HILLVIEW DR
MEQUON WI
53097-3205
US

IV. Provider business mailing address

8239 W HILLVIEW DR
MEQUON WI
53097-3205
US

V. Phone/Fax

Practice location:
  • Phone: 402-319-3770
  • Fax:
Mailing address:
  • Phone: 402-319-3770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number86-140
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number690
License Number StateNE

VIII. Authorized Official

Name: DR. TIFFANY KODAK
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 402-319-3770