Organization Name: | SOUTH STREET CLINIC LLC |
NPI Number: | 1235128356 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | ANNE ALEXA WESTON (CLINIC OWNER) |
Mailing Address: | 416 W South St Oconomowoc |
State: | WI US |
Postal Code: | 530662755 |
Phone Number: | 2625677673 |
Fax Number: | 2625673097 |
NPI Enumeration Date: | 10/20/2005 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | 1841 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WI |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |