Provider Demographics
NPI:1447423850
Name:FAMILY SERVICES OF NORTHEAST WI
Entity Type:Organization
Organization Name:FAMILY SERVICES OF NORTHEAST WI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-436-6800
Mailing Address - Street 1:300 CROOKS ST
Mailing Address - Street 2:PO BOX 22308
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4527
Mailing Address - Country:US
Mailing Address - Phone:920-436-6800
Mailing Address - Fax:920-437-3540
Practice Address - Street 1:1822 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2317
Practice Address - Country:US
Practice Address - Phone:920-436-4416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44018500Medicaid