Provider Demographics
NPI:1447702956
Name:WISCONSIN LUTHERAN CHILD & FAMILY SERVICE
Entity type:Organization
Organization Name:WISCONSIN LUTHERAN CHILD & FAMILY SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KLUG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-685-9522
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:ATTN: LINDA RANGEL
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:800-438-1772
Mailing Address - Fax:262-293-9737
Practice Address - Street 1:870 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-7418
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-293-9737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH-11075101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty