Healthcare Provider Details

I. General information

NPI: 1275961021
Provider Name (Legal Business Name): CHILDREN'S HOSPITAL OF WISCONSIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2013
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE PAIN CLINIC AND HEADACHE CLINIC
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE MAIL STATION 958 - SHEILA REUTEMAN
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-3133
  • Fax: 414-266-1761
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3186-57
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number662-124
License Number StateWI

VIII. Authorized Official

Name: WELDON GAGE
Title or Position: TREASURER/CHIEF FINANCIAL OFFICER
Credential:
Phone: 414-266-6401