Provider Demographics
NPI:1437394913
Name:COUNTY OF BURNETT
Entity Type:Organization
Organization Name:COUNTY OF BURNETT
Other - Org Name:DEPT OF HEALTH & HUMAN SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CORNELISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-349-7600
Mailing Address - Street 1:7410 COUNTY ROAD K
Mailing Address - Street 2:SUITE 280
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-9070
Mailing Address - Country:US
Mailing Address - Phone:715-349-7600
Mailing Address - Fax:715-349-2145
Practice Address - Street 1:7410 COUNTY ROAD K
Practice Address - Street 2:SUITE 280
Practice Address - City:SIREN
Practice Address - State:WI
Practice Address - Zip Code:54872-9070
Practice Address - Country:US
Practice Address - Phone:715-349-7600
Practice Address - Fax:715-349-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-11
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
WI251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44000800Medicaid
WI32978371Medicaid
WI43070700Medicaid