Organization
MIDWAY CLINICAL NEUROPSYCHOLOGIC INSTITUTE AND CHILDREN'S WELLNESS FOU
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SHELLIE D. LOCKE PHD (CHIEF EXECUTIVE OFFICER)
(262) 455-2919
Entity
Organization
Contact information
Practice address
1024 60TH STREET, SUITE 5, KENOSHA, WI 53140-4099
(262) 455-2919
(262) 455-2919
Mailing address
P.O. BOX 684, KENOSHA, WI 53141-0684
(262) 455-2919
(262) 455-2919
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
—
—
103T00000X
Psychologist
Primary
—
—
Other
Enumeration date
03/21/2019
Last updated
03/21/2019
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