Provider Demographics
NPI:1609801778
Name:WASHINGTON COUNTY WISCONSIN
Entity Type:Organization
Organization Name:WASHINGTON COUNTY WISCONSIN
Other - Org Name:WASHINGTON COUNTY HUMAN SERVICES MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-335-4591
Mailing Address - Street 1:333 E. WASHINGTON STREET
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2585
Mailing Address - Country:US
Mailing Address - Phone:262-335-4583
Mailing Address - Fax:262-335-6827
Practice Address - Street 1:333 E. WASHINGTON STREET
Practice Address - Street 2:SUITE 2100
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-2585
Practice Address - Country:US
Practice Address - Phone:262-335-4583
Practice Address - Fax:262-335-6827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 103T00000X, 103TC0700X
WI1968251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41760200Medicaid
WI43071300Medicaid
WI42140400Medicaid
WI43422500Medicaid
WI32976700Medicaid
WI43107500Medicaid
WI84285Medicare ID - Type UnspecifiedMEDICARE NUMBER
WI32976700Medicaid