Basic Information
| Provider Information | |||||||||
| NPI: | 1962575266 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MULTI-CULTURAL COUNSELING SERVICES II INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | RENEW COUNSELING SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1225 W HISTORIC MITCHELL ST | ||||||||
| Address2: | SUITE 223 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532043383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143834455 | ||||||||
| FaxNumber: | 4143836759 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 W HISTORIC MITCHELL ST | ||||||||
| Address2: | SUITE 223 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532043383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143834455 | ||||||||
| FaxNumber: | 4143836759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 12/01/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CROATT | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4143834455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 1792 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 42127400 | 05 | WI | MEDICAID |