Provider Demographics
NPI:1558537654
Name:FOND DU LAC COUNTY DCP CRISIS (NON-BILLABLE)
Entity Type:Organization
Organization Name:FOND DU LAC COUNTY DCP CRISIS (NON-BILLABLE)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS SYSTEMS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:A
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-929-3437
Mailing Address - Street 1:459 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4505
Mailing Address - Country:US
Mailing Address - Phone:920-929-3500
Mailing Address - Fax:
Practice Address - Street 1:459 E 1ST ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4505
Practice Address - Country:US
Practice Address - Phone:920-929-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOND DU LAC COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32975670Medicaid