MEDICARE: WIS. LUTHERAN CHILD & FAMILY SERVICES

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	1041C0700X	Clinical Social Worker	7143-123	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497029904
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WIS. LUTHERAN CHILD & FAMILY SERVICES

Provider Business Mailing Address
First Line	:	W175N11120 STONEWOOD DR
Second Line	:
City	:	GERMANTOWN
State	:	WI
Zip	:	53022-6511
Country	:	US
Telephone Number	:	262-345-5560
Fax Number	:	262-345-5562

Provider Business Practice Location Address
First Line	:	2345 N 25TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53206-1003
Country	:	US
Telephone Number	:	262-345-5560
Fax Number	:	262-345-5562

Authorized Official
Title or Position	:	PROGRAMS DIRECTOR
Name	:	DANIEL P NOMMENSEN
Credential	:	MA, LPC, CEAP
Telephone Number	:	262-345-5560

Provider Enumeration Date	:	03/01/2012
Last Update Date	:	03/01/2012

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