Provider Demographics
NPI:1053588228
Name:MILWAUKEE ACADEMY
Entity type:Organization
Organization Name:MILWAUKEE ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:K
Authorized Official - Last Name:DORN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:414-257-3141
Mailing Address - Street 1:9501 W WATERTOWN PLANK RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3552
Mailing Address - Country:US
Mailing Address - Phone:414-257-3141
Mailing Address - Fax:414-257-3151
Practice Address - Street 1:9501 W WATERTOWN PLANK RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3552
Practice Address - Country:US
Practice Address - Phone:414-257-3141
Practice Address - Fax:414-257-3151
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLINICARECORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41814600Medicaid