=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922404482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDREA KREMER THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2014
-----------------------------------------------------
Last Update Date | 11/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4402 S 68TH ST SUITE 100
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53220-3479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-748-6274
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2402 N 64TH ST
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53213-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-748-6274
-----------------------------------------------------
Fax | 414-321-0552
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | ANDREA MARY KREMER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 414-748-6274
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 7297-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------