Provider Demographics
NPI:1124469804
Name:ANNETTE E MADISON
Entity type:Organization
Organization Name:ANNETTE E MADISON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:ELISA
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:414-354-1030
Mailing Address - Street 1:PO BOX 90108
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-0108
Mailing Address - Country:US
Mailing Address - Phone:414-354-1030
Mailing Address - Fax:414-354-7584
Practice Address - Street 1:6051 W BROWN DEER RD
Practice Address - Street 2:SUITE 106
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-2263
Practice Address - Country:US
Practice Address - Phone:414-354-1030
Practice Address - Fax:414-354-7584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-10
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7034-123251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41003900Medicaid
WI3212Medicare PIN