Provider Demographics
NPI:1295224657
Name:NORTHWEST COUNSELING & GUIDANCE CLINIC
Entity Type:Organization
Organization Name:NORTHWEST COUNSELING & GUIDANCE CLINIC
Other - Org Name:NORTHWEST JOURNEY-GREEN BAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
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:715-349-5801
Mailing Address - Fax:888-625-8634
Practice Address - Street 1:123 S VAN BUREN
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4441
Practice Address - Country:US
Practice Address - Phone:920-336-8960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3197261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health