Provider Demographics
NPI:1417334988
Name:WILLOW CREEK RANCH, INC.
Entity Type:Organization
Organization Name:WILLOW CREEK RANCH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:S
Authorized Official - Last Name:PAPE
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED INSTRUCTO
Authorized Official - Phone:414-791-2509
Mailing Address - Street 1:7404 NORTHWEST HWY # 83
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-8903
Mailing Address - Country:US
Mailing Address - Phone:414-791-2509
Mailing Address - Fax:
Practice Address - Street 1:7404 NORTHWEST HWY # 83
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-8903
Practice Address - Country:US
Practice Address - Phone:414-791-2509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI091707261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI091707Medicaid