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General NPI Number Information
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NPI Number | 1285716308
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Entity Type | Organization
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Legal Business Name | RAVENSWOOD CLINIC INC
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Dates
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Enumeration Date | 10/19/2006
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Last Update Date | 03/27/2014
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Provider Practice Location Address
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Address Line | 2266 N PROSPECT AVE SUITE 608
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City | MILWAUKEE
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State | WI
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Zip | 53202-6306
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Country | US
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Telephone | 414-224-0492
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Fax | 414-224-8112
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Provider Business Mailing Address
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Address Line | 2266 N PROSPECT AVE SUITE 326
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City | MILWAUKEE
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State | WI
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Zip | 53202-6306
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Country | US
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Telephone | 414-224-0492
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Fax | 414-224-8112
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. ANTHONY FRANCIS WERTH JR.
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Credential | MS
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Telephone | 414-224-0492
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 2118
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License Number State | WI
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