Provider Demographics
NPI:1033531108
Name:WHITE EAGLE, JOSEPH SR (SAC)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:WHITE EAGLE
Suffix:SR
Gender:M
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S2845 WHITE EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-9064
Mailing Address - Country:US
Mailing Address - Phone:608-355-1240
Mailing Address - Fax:608-355-9588
Practice Address - Street 1:S2845 WHITE EAGLE RD
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-9064
Practice Address - Country:US
Practice Address - Phone:608-355-1240
Practice Address - Fax:608-355-9588
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16099-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)