Healthcare Provider Details

I. General information

NPI: 1558593129
Provider Name (Legal Business Name): TRANSFORMATIONSERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 08/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 N 23RD ST 212
MILWAUKEE WI
53233-3300
US

IV. Provider business mailing address

835 N 23RD ST 212
MILWAUKEE WI
53233-3300
US

V. Phone/Fax

Practice location:
  • Phone: 414-933-7083
  • Fax: 414-933-7883
Mailing address:
  • Phone: 414-933-7083
  • Fax: 414-933-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15226-130
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1198
License Number StateWI

VIII. Authorized Official

Name: DR. INGRID DIANN HICKS
Title or Position: CLINICAL & EXECUTIVE DIRECTOR
Credential: PH.D
Phone: 414-933-7083