Basic Information
| Provider Information | |||||||||
| NPI: | 1053588228 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILWAUKEE ACADEMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9501 W WATERTOWN PLANK RD | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142573141 | ||||||||
| FaxNumber: | 4142573151 | ||||||||
| Practice Location | |||||||||
| Address1: | 9501 W WATERTOWN PLANK RD | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142573141 | ||||||||
| FaxNumber: | 4142573151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2008 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | DORN | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4142573141 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLINICARECORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 41814600 | 05 | WI | MEDICAID |