Healthcare Provider Details

I. General information

NPI: 1467366039
Provider Name (Legal Business Name): HEART OF LYNN ADULT FAMILY HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9617 W GOODRICH AVE
MILWAUKEE WI
53224-2735
US

IV. Provider business mailing address

4113 N 73RD ST
MILWAUKEE WI
53216-1043
US

V. Phone/Fax

Practice location:
  • Phone: 414-394-1049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name: DESTINY POLK
Title or Position: OWNER
Credential:
Phone: 414-394-1049