MEDICARE: MR. FRANK AUSTIN BACCHUS M DIV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	225124	WI

General Provider Information

NPI Number	:	1053581660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FRANK AUSTIN BACCHUS M DIV

Provider Business Mailing Address
First Line	:	2925 S AMOR DR
Second Line	:
City	:	NEW BERLIN
State	:	WI
Zip	:	53146-2309
Country	:	US
Telephone Number	:	262-521-3000
Fax Number	:	262-521-3371

Provider Business Practice Location Address
First Line	:	2925 S AMOR DR
Second Line	:
City	:	NEW BERLIN
State	:	WI
Zip	:	53146-2309
Country	:	US
Telephone Number	:	262-521-3000
Fax Number	:	262-521-3371

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2008
Last Update Date	:	03/11/2008

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