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General NPI Number Information
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NPI Number | 1821312059
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Entity Type | Organization
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Legal Business Name | AUTISM INTERVENTION MILWAUKEE
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Dates
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Enumeration Date | 03/17/2010
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Last Update Date | 03/17/2010
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Provider Practice Location Address
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Address Line | 2645 N MAYFAIR RD SUITE 250
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City | WAUWATOSA
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State | WI
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Zip | 53226-1304
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Country | US
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Telephone | 414-256-0077
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Fax | 414-256-0090
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Provider Business Mailing Address
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Address Line | 2645 N MAYFAIR RD SUITE 250
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City | WAUWATOSA
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State | WI
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Zip | 53226-1304
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Country | US
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Telephone | 414-256-0077
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Fax | 414-256-0090
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | DR. KATHLEEN BRODERICK WOODY
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Credential | PSY.D.
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Telephone | 414-256-0077
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 2041-057
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License Number State | WI
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