Provider Demographics
NPI:1437336583
Name:BAYSHORE COUNSELING NETWORK
Entity Type:Organization
Organization Name:BAYSHORE COUNSELING NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARI
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MSE
Authorized Official - Phone:920-469-8890
Mailing Address - Street 1:2345 E MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-3764
Mailing Address - Country:US
Mailing Address - Phone:920-469-8890
Mailing Address - Fax:920-406-3909
Practice Address - Street 1:2345 E MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-3764
Practice Address - Country:US
Practice Address - Phone:920-469-8890
Practice Address - Fax:920-406-3909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1951-125251S00000X
WI13018-020251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42210300Medicaid