Provider Demographics
NPI:1699964817
Name:FRANK J ELMUDESI PSYD LTD
Entity type:Organization
Organization Name:FRANK J ELMUDESI PSYD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:ELMUDESI PSYD LTD
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:251-847-6207
Mailing Address - Street 1:420 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-1709
Mailing Address - Country:US
Mailing Address - Phone:251-847-3094
Mailing Address - Fax:
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:251-847-3094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39128400103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39128400Medicaid
IL971620Medicare PIN
WI000044279Medicare PIN
WI000044935Medicare PIN