Provider Demographics
NPI:1003079708
Name:LIPFORD, CHARLES D (CSAC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:D
Last Name:LIPFORD
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:220 E LA CROSSE ST.
Mailing Address - Street 2:JUNEAU COUNTY HUMAN SERVICES
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-2101
Mailing Address - Country:US
Mailing Address - Phone:608-847-2400
Mailing Address - Fax:608-847-9599
Practice Address - Street 1:220 E LA CROSSE ST.
Practice Address - Street 2:JUNEAU COUNTY HUMAN SERVICES
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-2101
Practice Address - Country:US
Practice Address - Phone:608-847-2400
Practice Address - Fax:608-847-9599
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302375101YA0400X
WI15413-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003079708Medicaid