Provider Demographics
NPI:1609198027
Name:GREAT LAKES MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:GREAT LAKES MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VRANIAK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:715-790-2100
Mailing Address - Street 1:W3177 HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGBROOK
Mailing Address - State:WI
Mailing Address - Zip Code:54875-9314
Mailing Address - Country:US
Mailing Address - Phone:715-790-2100
Mailing Address - Fax:
Practice Address - Street 1:15910 W COMPANY LAKE RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-5320
Practice Address - Country:US
Practice Address - Phone:715-790-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4339125101YP2500X
WI885103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty