Provider Demographics
NPI:1164516506
Name:STATE OF WISCONSIN
Entity Type:Organization
Organization Name:STATE OF WISCONSIN
Other - Org Name:WINNEBAGO MENTAL HEALTH INSTITUTE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:KNEEPKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-235-4910
Mailing Address - Street 1:1300 SOUTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:WI
Mailing Address - Zip Code:54985-0009
Mailing Address - Country:US
Mailing Address - Phone:920-235-4910
Mailing Address - Fax:920-237-2043
Practice Address - Street 1:1300 SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-0009
Practice Address - Country:US
Practice Address - Phone:920-235-4910
Practice Address - Fax:920-237-2043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI250283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10063000Medicaid
WI10063000Medicaid