Provider Demographics
NPI:1275733602
Name:NORTHEAST WISCONSIN BEHAVIORAL HEALTH SC
Entity Type:Organization
Organization Name:NORTHEAST WISCONSIN BEHAVIORAL HEALTH SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO, PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SUZETTE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KOSNAR-TITTL
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:920-884-2175
Mailing Address - Street 1:529 SOUTH JEFFERSON STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4125
Mailing Address - Country:US
Mailing Address - Phone:920-884-2175
Mailing Address - Fax:920-884-6735
Practice Address - Street 1:529 SOUTH JEFFERSON STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4125
Practice Address - Country:US
Practice Address - Phone:920-884-2175
Practice Address - Fax:920-884-6735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4044-123101YM0800X
101YM0800X
WI2376 125101YP2500X
WI4044 1231041C0700X
WI489 124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39722900OtherPROVIDER MEDICAID #
WI000044900OtherCLINICMEDICARE# GREENBAY
WI1275733602OtherCLINIC NPI#
WI000044905OtherCLINICMEDICARE#OSHKOSH
1285736249OtherPROVIDER NPI
WI000144900OtherPROVIDERMEDICARE#GREENBAY
WI000144905OtherPROVIDERMEDICARE#OSHKOSH
WI4225100OtherCLINIC MEDICAID #