=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154402501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY TREE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 02/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 508 CAMPUS ST SUITE 6
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53563-1750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-868-5122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 508 CAMPUS ST SUITE 6
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53563-1750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-868-5122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | LOIS ANN HADLEY
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 608-868-5122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------