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General NPI Number Information
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NPI Number | 1730853870
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Entity Type | Organization
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Legal Business Name | ERC WISCONSIN, LLC
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Dates
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Enumeration Date | 08/03/2021
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Last Update Date | 02/03/2022
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Provider Practice Location Address
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Address Line | 2500 N MAYFAIR RD STE 600
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City | WAUWATOSA
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State | WI
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Zip | 53226-1428
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Country | US
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Telephone | 414-727-4455
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Fax |
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Provider Business Mailing Address
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Address Line | 7351 E LOWRY BLVD SUITE #200
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City | DENVER
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State | CO
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Zip | 80256-1428
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Country | US
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Telephone | 414-727-4455
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Fax |
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Authorized Official
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Title or Position | CONTRACTING & CREDENTIALING MANAGER
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Name | MARINA SHEPEL
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Credential |
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Telephone | 425-214-9321
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 283Q00000X
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Taxonomy Name | Psychiatric Hospital
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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