Provider Demographics
NPI:1336327410
Name:COUNTY OF COOK
Entity Type:Organization
Organization Name:COUNTY OF COOK
Other - Org Name:COOK CO WILDERNESS OUTPATIENT TREATMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:FUTTERER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-387-3020
Mailing Address - Street 1:411 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GRAND MARAIS
Mailing Address - State:MN
Mailing Address - Zip Code:55604-2307
Mailing Address - Country:US
Mailing Address - Phone:218-387-3020
Mailing Address - Fax:
Practice Address - Street 1:411 W 2ND ST
Practice Address - Street 2:
Practice Address - City:GRAND MARAIS
Practice Address - State:MN
Practice Address - Zip Code:55604-2307
Practice Address - Country:US
Practice Address - Phone:218-387-3020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN810854-1-CDT101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN407791100Medicaid