Provider Demographics
NPI:1194842880
Name:FAMILY SERVICES OF NORTHEAST WISCONSIN
Entity Type:Organization
Organization Name:FAMILY SERVICES OF NORTHEAST WISCONSIN
Other - Org Name:FAMILY SERVICES - FOX VALLEY DAY TREATMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT-CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-436-6800
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:920-432-5966
Practice Address - Street 1:626 S IRWIN AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3304
Practice Address - Country:US
Practice Address - Phone:920-433-3372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1332251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43002300Medicaid