Provider Demographics
NPI:1073759577
Name:DETRIE, CLARISSA (MSW)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:DETRIE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:
Other - Last Name:WINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:300 CROOKS ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4527
Mailing Address - Country:US
Mailing Address - Phone:920-436-6800
Mailing Address - Fax:920-437-3540
Practice Address - Street 1:300 CROOKS ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4527
Practice Address - Country:US
Practice Address - Phone:920-436-6800
Practice Address - Fax:920-437-3540
Is Sole Proprietor?:No
Enumeration Date:2009-01-05
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1073759577Medicaid