Provider Demographics
NPI:1548387657
Name:NORTHWEST JOURNEY - BLACK RIVER FALLS
Entity Type:Organization
Organization Name:NORTHWEST JOURNEY - BLACK RIVER FALLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:KALAMBOKIDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-327-4402
Mailing Address - Street 1:N6643 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-5852
Mailing Address - Country:US
Mailing Address - Phone:715-284-1100
Mailing Address - Fax:715-284-1145
Practice Address - Street 1:N6643 COUNTY ROAD A
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-5852
Practice Address - Country:US
Practice Address - Phone:715-284-1100
Practice Address - Fax:715-284-1145
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST COUNSELING AND GUIDANCE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2655261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN85575OtherPREFERRED ONE
WI43008800Medicaid
MN42626OtherHEALTH PARTNERS