Provider Demographics
NPI:1508574328
Name:SWEETGRASS BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:SWEETGRASS BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEGRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:715-280-8130
Mailing Address - Street 1:102 E GREEN BAY ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2444
Mailing Address - Country:US
Mailing Address - Phone:715-280-8130
Mailing Address - Fax:715-280-8138
Practice Address - Street 1:102 E GREEN BAY ST STE 101
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2444
Practice Address - Country:US
Practice Address - Phone:715-280-8130
Practice Address - Fax:715-280-8138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-10
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health