Healthcare Provider Details

I. General information

NPI: 1801807375
Provider Name (Legal Business Name): WISCONSIN EATING DISORDER SPECIALISTS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34700 VALLEY RD
OCONOMOWOC WI
53066-4500
US

IV. Provider business mailing address

3630 N HICKORY LN
OCONOMOWOC WI
53066-4532
US

V. Phone/Fax

Practice location:
  • Phone: 262-646-1387
  • Fax: 262-646-7067
Mailing address:
  • Phone: 262-646-1387
  • Fax: 262-646-7067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: THEODORE WELTZIN
Title or Position: OWNER
Credential: MD
Phone: 262-646-4411