| South Street Clinic Llc | |
|
416 W South St Oconomowoc WI 53066-2755 | |
| (262) 567-7673 | |
| (262) 567-3097 |
| Full Name | South Street Clinic Llc |
|---|---|
| Speciality | Psychologist - Clinical |
| Location | 416 W South St, Oconomowoc, Wisconsin |
| Authorized Official Name and Position | Anne Alexa Weston (CLINIC OWNER) |
| Authorized Official Contact | 2625677673 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| South Street Clinic Llc 416 W South St Oconomowoc WI 53066-2755 Ph: (262) 567-7673 | South Street Clinic Llc 416 W South St Oconomowoc WI 53066-2755 Ph: (262) 567-7673 |
| NPI Number | 1235128356 |
|---|---|
| Provider Enumeration Date | 10/20/2005 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1235128356 | NPI | - | NPPES |
| 42217900 | Medicaid | WI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | 1841 (Wisconsin) | Primary |
News Archive
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› Verified 7 days ago
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