Provider Demographics
NPI:1558393009
Name:CATHOLIC CHARITIES OF THE DIOCESE OF LACROSSE, INC.
Entity Type:Organization
Organization Name:CATHOLIC CHARITIES OF THE DIOCESE OF LACROSSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEACON, EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SAGE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:608-782-0710
Mailing Address - Street 1:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53082-1127
Mailing Address - Country:US
Mailing Address - Phone:920-457-6750
Mailing Address - Fax:920-457-8350
Practice Address - Street 1:3710 EAST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54602-0266
Practice Address - Country:US
Practice Address - Phone:608-782-0710
Practice Address - Fax:608-782-0702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42215500Medicaid
WI42215500Medicaid
WI=========013OtherBLUE CROSS & BLUE SHIELD