=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699155648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR LANGUAGE ACQUISITION AND SOCIAL SKILLS INTERVENTION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2015
-----------------------------------------------------
Last Update Date | 06/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8239 W HILLVIEW DR
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53097-3205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-319-3770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8239 W HILLVIEW DR
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53097-3205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-319-3770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. TIFFANY KODAK
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 402-319-3770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 690
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 86-140
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------