Provider Demographics
NPI:1215368139
Name:WISE MIND MENTAL HEALTH CLINIC, LLC
Entity Type:Organization
Organization Name:WISE MIND MENTAL HEALTH CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:FABER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:715-384-0080
Mailing Address - Street 1:601 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-4512
Mailing Address - Country:US
Mailing Address - Phone:715-384-0080
Mailing Address - Fax:715-384-0090
Practice Address - Street 1:601 E 3RD ST
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-4512
Practice Address - Country:US
Practice Address - Phone:715-384-0080
Practice Address - Fax:715-384-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK100125984Medicare PIN