Provider Demographics
NPI:1558508499
Name:CATHOLIC CHARITIES OF THE DIOCESE OF LA CROSSE, INC.
Entity Type:Organization
Organization Name:CATHOLIC CHARITIES OF THE DIOCESE OF LA CROSSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position: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 1:401 5TH ST STE 235
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-5468
Practice Address - Country:US
Practice Address - Phone:715-849-3311
Practice Address - Fax:715-849-8414
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC CHARITIES OF THE DIOCESE OF LA CROSSE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
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
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1558393009Medicaid
WI1558393009Medicaid
WI=========013OtherBLUE CROSS/BLUE SHIELD