Healthcare Provider Details

I. General information

NPI: 1790964674
Provider Name (Legal Business Name): SCHOOL DISTRICT OF KETTLE MORAINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 A J ALLEN CIR
WALES WI
53183-9649
US

IV. Provider business mailing address

563 A J ALLEN CIR
WALES WI
53183-9649
US

V. Phone/Fax

Practice location:
  • Phone: 262-968-6300
  • Fax: 262-968-6390
Mailing address:
  • Phone: 262-968-6300
  • Fax: 262-968-6390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: DR. BETTY WOMACK
Title or Position: ASST SUPT OF PUPIL SERVICES
Credential: ED.D.
Phone: 262-968-6300