Healthcare Provider Details

I. General information

NPI: 1669648960
Provider Name (Legal Business Name): ST. CHARLES YOUTH & FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 W WATERTOWN PLANK RD
WAUWATOSA WI
53226-3552
US

IV. Provider business mailing address

151 S 84TH ST
MILWAUKEE WI
53214-1456
US

V. Phone/Fax

Practice location:
  • Phone: 414-476-3710
  • Fax: 414-778-5985
Mailing address:
  • Phone: 414-476-3710
  • Fax: 414-778-5985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number1005239
License Number StateWI

VIII. Authorized Official

Name: MS. CATHERINE CONNOLLY
Title or Position: PRESIDENT
Credential:
Phone: 414-476-3710