Basic Information
| Provider Information | |||||||||
| NPI: | 1326106998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTHEWS | ||||||||
| FirstName: | GLENDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 W HISTORIC MITCHELL ST STE 223 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532043383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143834455 | ||||||||
| FaxNumber: | 4143836759 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 W HISTORIC MITCHELL ST STE 223 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532043383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143834455 | ||||||||
| FaxNumber: | 4143836759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 06/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 10434 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 39399100 | 05 | WI | MEDICAID |