Provider Demographics
NPI:1285641647
Name:WIRKUS, JOHN NICHOLAS
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:NICHOLAS
Last Name:WIRKUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:WIRKUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADC3
Mailing Address - Street 1:111 WEST ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53038-9503
Mailing Address - Country:US
Mailing Address - Phone:920-699-3703
Mailing Address - Fax:
Practice Address - Street 1:16535 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5936
Practice Address - Country:US
Practice Address - Phone:262-542-3255
Practice Address - Fax:262-821-6180
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)