Provider Demographics
NPI:1275525925
Name:FAMILY SERVICES OF NORTHEAST WISCONSIN INC
Entity Type:Organization
Organization Name:FAMILY SERVICES OF NORTHEAST WISCONSIN INC
Other - Org Name:FAMILY SERVICES OF NEW
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:920-436-6800
Mailing Address - Street 1:1810 APPLETON RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1110
Mailing Address - Country:US
Mailing Address - Phone:920-739-4226
Mailing Address - Fax:920-739-7639
Practice Address - Street 1:1810 APPLETON RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1110
Practice Address - Country:US
Practice Address - Phone:920-739-4226
Practice Address - Fax:920-739-7639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1333261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42222600Medicaid
WI000085206Medicare ID - Type Unspecified