1275733602 NPI number — NORTHEAST WISCONSIN BEHAVIORAL HEALTH SC

Table of content: (NPI 1275733602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275733602 NPI number — NORTHEAST WISCONSIN BEHAVIORAL HEALTH SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST WISCONSIN BEHAVIORAL HEALTH SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275733602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
529 SOUTH JEFFERSON STREET
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54301-4125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-884-2175
Provider Business Mailing Address Fax Number:
920-884-6735

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
529 SOUTH JEFFERSON STREET
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54301-4125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-884-2175
Provider Business Practice Location Address Fax Number:
920-884-6735
Provider Enumeration Date:
07/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KOSNAR-TITTL
Authorized Official First Name:
SUZETTE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER, CEO, PROVIDER
Authorized Official Telephone Number:
920-884-2175

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  4044-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X , with the licence number: 2376 125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 4044 123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 489 124 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 39722900 . This is a "PROVIDER MEDICAID #" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 000044900 . This is a "CLINICMEDICARE# GREENBAY" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1275733602 . This is a "CLINIC NPI#" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 000044905 . This is a "CLINICMEDICARE#OSHKOSH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1285736249 . This is a "PROVIDER NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000144900 . This is a "PROVIDERMEDICARE#GREENBAY" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 000144905 . This is a "PROVIDERMEDICARE#OSHKOSH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 4225100 . This is a "CLINIC MEDICAID #" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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