Provider Demographics
NPI:1306909312
Name:ELMUDESI, FRANK J (PSYD)
Entity type:Individual
Prefix:
First Name:FRANK
Middle Name:J
Last Name:ELMUDESI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 956
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-0956
Mailing Address - Country:US
Mailing Address - Phone:262-374-0068
Mailing Address - Fax:251-847-3096
Practice Address - Street 1:420 MADISON ST
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-1709
Practice Address - Country:US
Practice Address - Phone:262-374-0068
Practice Address - Fax:251-847-3096
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2132057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39128400Medicaid
WI39128400Medicaid
WI000144279Medicare PIN
WI000144935Medicare PIN