Healthcare Provider Details

I. General information

NPI: 1639343320
Provider Name (Legal Business Name): WELLPOINT CARE NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 W. CAPITOL DR
MILWAUKEE WI
53222-1706
US

IV. Provider business mailing address

8901 W. CAPITOL DR
MILWAUKEE WI
53222-1706
US

V. Phone/Fax

Practice location:
  • Phone: 414-465-5751
  • Fax: 414-463-2770
Mailing address:
  • Phone: 414-465-5751
  • Fax: 414-463-2770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateWI

VIII. Authorized Official

Name: DR. JODY ANN PAHLAVAN
Title or Position: VICE PRESIDENT OF CLINICAL SERVICES
Credential: PSY.D.
Phone: 414-463-1880