Healthcare Provider Details

I. General information

NPI: 1427870799
Provider Name (Legal Business Name): COURTNEY WALLACE APSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: COURTNEY BECKER APSW

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S 76TH ST
MILWAUKEE WI
53214-1599
US

IV. Provider business mailing address

620 S 76TH ST
MILWAUKEE WI
53214-1599
US

V. Phone/Fax

Practice location:
  • Phone: 414-292-4242
  • Fax: 414-453-2538
Mailing address:
  • Phone: 414-292-4242
  • Fax: 414-453-2538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number134408
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: