Provider Demographics
NPI:1275650350
Name:NORTHWEST COUNSELING & GUIDANCE CLINIC
Entity Type:Organization
Organization Name:NORTHWEST COUNSELING & GUIDANCE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING 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:715-327-4322
Mailing Address - Street 1:203 UNITED WAY
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-8938
Mailing Address - Country:US
Mailing Address - Phone:715-327-4322
Mailing Address - Fax:715-327-8509
Practice Address - Street 1:5655 N. 28TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-9709
Practice Address - Country:US
Practice Address - Phone:715-675-5454
Practice Address - Fax:715-675-0545
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST COUNSELING AND GUIDANCE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2404261QM0855X
WI261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43007000Medicaid
MN42626OtherHEALTH PARTNERS
MN85575OtherPREFERRED ONE
WI4300700Medicaid