Provider Demographics
NPI:1346233350
Name:ST. CROIX CHIPPEWA INDIANS OF WI
Entity Type:Organization
Organization Name:ST. CROIX CHIPPEWA INDIANS OF WI
Other - Org Name:ST. CROIX TRIBAL BEHAVIORAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-349-8554
Mailing Address - Street 1:4404 STATE ROAD 70
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:WI
Mailing Address - Zip Code:54893-9251
Mailing Address - Country:US
Mailing Address - Phone:877-455-1901
Mailing Address - Fax:715-349-8528
Practice Address - Street 1:4404 STATE ROAD 70
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893-9251
Practice Address - Country:US
Practice Address - Phone:877-455-1901
Practice Address - Fax:715-349-8528
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. CROIX CHIPPEWA INDIANS OF WI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-24
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2217101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42220400Medicaid
WI1831170091Medicaid