Provider Demographics
NPI:1053397869
Name:EASTER SEALS SOUTHEAST WISCONSIN INC
Entity type:Organization
Organization Name:EASTER SEALS SOUTHEAST WISCONSIN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-963-5902
Mailing Address - Street 1:2222 S 114TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1031
Mailing Address - Country:US
Mailing Address - Phone:414-449-4444
Mailing Address - Fax:414-571-5568
Practice Address - Street 1:2222 S 114TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1031
Practice Address - Country:US
Practice Address - Phone:414-449-4444
Practice Address - Fax:414-571-5568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X, 235Z00000X
WI261QR0400X261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41209100Medicaid
WI41209100Medicaid
WI000080305Medicare PIN