Provider Demographics
NPI:1487051272
Name:EXTENDEED CARE CENTER
Entity type:Organization
Organization Name:EXTENDEED CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BYKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, APSW
Authorized Official - Phone:414-384-2000
Mailing Address - Street 1:3055 S FOUNTAIN SQUARE BLVD
Mailing Address - Street 2:APT 207
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-3999
Mailing Address - Country:US
Mailing Address - Phone:414-384-2000
Mailing Address - Fax:
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:BLDG 70-E-106
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-0001
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1291061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty