Provider Demographics
NPI:1245514520
Name:FAMILY IMPACT, INC
Entity type:Organization
Organization Name:FAMILY IMPACT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERRICKA
Authorized Official - Middle Name:
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, CAPSW
Authorized Official - Phone:262-635-5135
Mailing Address - Street 1:6601 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4058
Mailing Address - Country:US
Mailing Address - Phone:262-635-5135
Mailing Address - Fax:262-995-7333
Practice Address - Street 1:829 S GREEN BAY RD
Practice Address - Street 2:STE 109
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4058
Practice Address - Country:US
Practice Address - Phone:262-880-5864
Practice Address - Fax:262-995-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-04
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4425-125251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health