Organization
SOUTH STREET CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ANNE ALEXA WESTON PHD (CLINIC OWNER)
(262) 567-7673
Entity
Organization
Contact information
Practice address
416 W SOUTH ST, OCONOMOWOC, WI 53066-2755
(262) 567-7673
(262) 567-3097
Mailing address
416 W SOUTH ST, OCONOMOWOC, WI 53066-2755
(262) 567-7673
(262) 567-3097
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
1841
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
42217900
—
WI
Enumeration date
10/20/2005
Last updated
08/22/2020
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