Provider Demographics
NPI:1992106595
Name:WADE KOSKI LLC
Entity type:Organization
Organization Name:WADE KOSKI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:414-467-2477
Mailing Address - Street 1:4402 S 68TH ST
Mailing Address - Street 2:SUITE #100
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-3479
Mailing Address - Country:US
Mailing Address - Phone:414-467-2477
Mailing Address - Fax:414-321-0552
Practice Address - Street 1:4402 S 68TH ST
Practice Address - Street 2:SUITE #100
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-3479
Practice Address - Country:US
Practice Address - Phone:414-467-2477
Practice Address - Fax:414-321-0552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40959600Medicaid