Provider Demographics
NPI:1407271695
Name:DRIFTLESS RECOVERY SERVICES, INC.
Entity Type:Organization
Organization Name:DRIFTLESS RECOVERY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CO-FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:A
Authorized Official - Last Name:KNUTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-386-6154
Mailing Address - Street 1:114 VERNON ST
Mailing Address - Street 2:
Mailing Address - City:WESTBY
Mailing Address - State:WI
Mailing Address - Zip Code:54667-1122
Mailing Address - Country:US
Mailing Address - Phone:608-386-6154
Mailing Address - Fax:
Practice Address - Street 1:444 MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-3261
Practice Address - Country:US
Practice Address - Phone:608-386-6154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12863-130101YA0400X
WI16304-130101YA0400X
WI1231-226101YM0800X
WI271822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1093001703OtherNPI
1215147558OtherNPI
39330PLOtherBCBS
1992787725OtherNPI
WI055508800Medicaid
1093001703OtherNPI
A93933Medicare UPIN