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NPI Code Detail

MEDICARE: WILLOWGLEN ACADEMY INC

MEDICARE: WILLOWGLEN ACADEMY INC
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
1261Q00000XClinic/Center2004WI

Other Identifiers

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

General Provider Information

NPI Number : 1619147048
Entity Type Code : Organization
Provider Name (Legal Business Name) : WILLOWGLEN ACADEMY INC
Provider Business Mailing Address
First Line : 4065 N 35TH ST
Second Line : SUITE N100
City : MILWAUKEE
State : WI
Zip : 53216-1705
Country : US
Telephone Number : 414-445-9180
Fax Number : 414-445-5995
Provider Business Practice Location Address
First Line : 4065 N 35TH ST
Second Line : SUITE N100
City : MILWAUKEE
State : WI
Zip : 53216-1705
Country : US
Telephone Number : 414-445-9180
Fax Number : 414-445-5995
Authorized Official
Title or Position : DIRECTOR OF OUTPATIENT SERVICES
Name : SHANNA MALONEY
Credential : LCSW
Telephone Number : 414-445-9180
Provider Enumeration Date : 02/29/2008
Last Update Date : 06/19/2014

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Directions to “WILLOWGLEN ACADEMY INC ” Practice Location

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