Basic Information
| Provider Information | |||||||||
| NPI: | 1619112679 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MULTI-CULTURAL COUNSELING SERVICES II INC. | ||||||||
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| OtherOrganizationName: | RENEW COUNSELING SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 W MITCHELL ST | ||||||||
| Address2: | #223 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532043383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143834455 | ||||||||
| FaxNumber: | 4143836759 | ||||||||
| Practice Location | |||||||||
| Address1: | 3975 N 68TH ST | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532162066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149338700 | ||||||||
| FaxNumber: | 4149332029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2008 | ||||||||
| LastUpdateDate: | 12/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | CROATT | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4143834455 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | WI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 261Q00000X | 1791 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 42127421 | 05 | WI | MEDICAID |