Organization
LIFE ENHANCEMENT SUPPORTIVE SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. TONYETTA L ROSS BS, SACIT (DIRECTOR)
(414) 690-0672
Entity
Organization
Contact information
Practice address
6001 W CENTER ST STE 201, MILWAUKEE, WI 53210-2154
(414) 444-2380
Mailing address
6001 W CENTER ST STE 201, MILWAUKEE, WI 53210-2154
(414) 444-2380
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
15896-130
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1184060998
NPI
WI
01
—
12088599
CAQH
WI
Enumeration date
11/25/2013
Last updated
11/25/2013
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