Provider Demographics
NPI:1598938557
Name:WAUSHARA COUNTY
Entity Type:Organization
Organization Name:WAUSHARA COUNTY
Other - Org Name:WAUSHARA COUNTY CRISIS INTERVENTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNT CLERK
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:IDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-787-6618
Mailing Address - Street 1:PO BOX 1230
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-1230
Mailing Address - Country:US
Mailing Address - Phone:920-787-6600
Mailing Address - Fax:920-787-6670
Practice Address - Street 1:230 W PARK STREET
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-9031
Practice Address - Country:US
Practice Address - Phone:920-787-6550
Practice Address - Fax:920-787-0421
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAUSHARA COUNTY CLINICAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-10
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1980251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32976970Medicaid