Provider Demographics
NPI:1558518076
Name:DOOR COUNTY DEPARTMENT OF COMMUNITY PROGRAMS
Entity Type:Organization
Organization Name:DOOR COUNTY DEPARTMENT OF COMMUNITY PROGRAMS
Other - Org Name:DOOR COUNTY COMMUNITY SUPPORT PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CSP COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:920-746-2345
Mailing Address - Street 1:421 NEBRASKA ST
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-2225
Mailing Address - Country:US
Mailing Address - Phone:920-746-2345
Mailing Address - Fax:920-746-2439
Practice Address - Street 1:421 NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-2225
Practice Address - Country:US
Practice Address - Phone:920-746-2345
Practice Address - Fax:920-746-2439
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOOR COUNTY COMMUNITY SUPPORT PROGRAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1510-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39693300Medicaid