Healthcare Provider Details

I. General information

NPI: 1679981328
Provider Name (Legal Business Name): LIFE CHANGING MINISTRIES SUBSTANCE ABUSE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 W NORTH AVE 2ND FLOOR
MILWAUKEE WI
53205
US

IV. Provider business mailing address

1134 W NORTH AVE 2ND FLOOR
MILWAUKEE WI
53205-1333
US

V. Phone/Fax

Practice location:
  • Phone: 414-269-9660
  • Fax: 414-755-0698
Mailing address:
  • Phone: 414-269-9660
  • Fax: 414-755-0698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number3045
License Number StateWI

VIII. Authorized Official

Name: KARINA CHELSKY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 414-467-8884