Provider Demographics
NPI:1225155393
Name:NORTHWEST COUNSELING & GUIDANCE CLINIC
Entity Type:Organization
Organization Name:NORTHWEST COUNSELING & GUIDANCE CLINIC
Other - Org Name:NORTHWEST JOURNEY-DEPERE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAURER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-349-7069
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-0309
Mailing Address - Country:US
Mailing Address - Phone:715-349-7069
Mailing Address - Fax:888-625-8634
Practice Address - Street 1:1119 W KENNEDY AVE
Practice Address - Street 2:STE A
Practice Address - City:KIMBERLY
Practice Address - State:WI
Practice Address - Zip Code:54136-2213
Practice Address - Country:US
Practice Address - Phone:920-364-9668
Practice Address - Fax:888-625-8634
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST COUNSELING & GUIDANCE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-23
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2160261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43005000Medicaid
MN42626OtherHEALTH PARTNERS
MN85575OtherPREFERRED ONE