Provider Demographics
NPI:1700817657
Name:AGNESIAN HEALTHCARE
Entity Type:Organization
Organization Name:AGNESIAN HEALTHCARE
Other - Org Name:PSYCHIATRIC ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:SALASEK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:920-885-2780
Mailing Address - Street 1:200 FRONT ST
Mailing Address - Street 2:SUITE 3D
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1667
Mailing Address - Country:US
Mailing Address - Phone:920-885-2780
Mailing Address - Fax:920-885-2788
Practice Address - Street 1:200 FRONT ST
Practice Address - Street 2:SUITE 3D
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-1667
Practice Address - Country:US
Practice Address - Phone:920-885-2780
Practice Address - Fax:920-885-2788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1753261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)