1902923568 NPI number — NORTHWEST COUNSELING AND GUIDANCE CLINIC- SIREN DAY TREATMENT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902923568 NPI number — NORTHWEST COUNSELING AND GUIDANCE CLINIC- SIREN DAY TREATMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST COUNSELING AND GUIDANCE CLINIC- SIREN DAY TREATMENT
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:
1902923568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 309
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIREN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54872-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-349-7069
Provider Business Mailing Address Fax Number:
888-625-8634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24996 ST RD 35
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIREN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54872-9239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-349-7069
Provider Business Practice Location Address Fax Number:
888-625-8634
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAURER
Authorized Official First Name:
JACKIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE SUPERVISOR
Authorized Official Telephone Number:
715-349-7069

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X , with the licence number:  2290 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HUMANA . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 42626 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 43004000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: VALUE OPTIONS . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7H956NO . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: PREFERRED ONE . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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