Provider Demographics
NPI:1154402501
Name:FAMILY TREE
Entity type:Organization
Organization Name:FAMILY TREE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:608-868-5122
Mailing Address - Street 1:508 CAMPUS ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53563-1750
Mailing Address - Country:US
Mailing Address - Phone:608-868-5122
Mailing Address - Fax:
Practice Address - Street 1:508 CAMPUS ST
Practice Address - Street 2:SUITE 6
Practice Address - City:MILTON
Practice Address - State:WI
Practice Address - Zip Code:53563-1750
Practice Address - Country:US
Practice Address - Phone:608-868-5122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42208000Medicaid
WI000084403Medicare ID - Type Unspecified