Provider Demographics
NPI:1700839644
Name:NORTHLAND COMMUNITY SERVICES INC
Entity Type:Organization
Organization Name:NORTHLAND COMMUNITY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:S
Authorized Official - Last Name:MATTHEW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:608-296-2139
Mailing Address - Street 1:161 SPRING ST
Mailing Address - Street 2:PO BOX 248
Mailing Address - City:WESTFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53964-9068
Mailing Address - Country:US
Mailing Address - Phone:608-296-2139
Mailing Address - Fax:608-296-1590
Practice Address - Street 1:161 SPRING ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:WI
Practice Address - Zip Code:53964-9068
Practice Address - Country:US
Practice Address - Phone:608-296-2139
Practice Address - Fax:608-296-1590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI822103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42119500Medicaid