Provider Demographics
NPI:1609040351
Name:ACADEMY OF LEARNING AND LEADERSHIP
Entity type:Organization
Organization Name:ACADEMY OF LEARNING AND LEADERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:M.
Authorized Official - Middle Name:CAMILLE
Authorized Official - Last Name:MORTIMORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:414-372-3942
Mailing Address - Street 1:1530 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-2101
Mailing Address - Country:US
Mailing Address - Phone:414-372-3942
Mailing Address - Fax:414-372-8260
Practice Address - Street 1:1530 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-2101
Practice Address - Country:US
Practice Address - Phone:414-372-3942
Practice Address - Fax:414-372-8260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44241900Medicaid