Provider Demographics
NPI:1649397654
Name:FAMILY SERVICES OF NORTHEAST WISCONSIN, INC.
Entity Type:Organization
Organization Name:FAMILY SERVICES OF NORTHEAST WISCONSIN, INC.
Other - Org Name:FAMILY SERVICES - FOX VALLEY DAY TREATMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT-CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-436-6800
Mailing Address - Street 1:300 CROOKS ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4527
Mailing Address - Country:US
Mailing Address - Phone:920-436-6800
Mailing Address - Fax:
Practice Address - Street 1:1500 W ROGERS AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-5007
Practice Address - Country:US
Practice Address - Phone:920-954-6804
Practice Address - Fax:920-954-6806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2561251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43008200Medicaid