1831442359 NPI number — BEHAVIORAL HEALTH CLINIC, LLC

Table of content: (NPI 1831442359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831442359 NPI number — BEHAVIORAL HEALTH CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEHAVIORAL HEALTH CLINIC, LLC
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:
BEHAVIORAL HEALTH CLINIC OF WAUSAU
Provider Other Organization Name Type Code:
4
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:
1831442359
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 S 36TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUSAU
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54401-3930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-842-9500
Provider Business Mailing Address Fax Number:
715-848-0425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 S 36TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUSAU
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54401-3930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-842-9500
Provider Business Practice Location Address Fax Number:
715-848-0425
Provider Enumeration Date:
10/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
FANCHER
Authorized Official First Name:
CHARITY
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
OPERATIONS ADMINISTRATOR
Authorized Official Telephone Number:
715-842-9500

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 2632-057 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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