Provider Demographics
NPI:1710986989
Name:FAMILY SERVICE OF WINONA
Entity Type:Organization
Organization Name:FAMILY SERVICE OF WINONA
Other - Org Name:FAMILY SERVICE OF WINONA - MARGARET SIMPSON HOME
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMIN MANAGER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:V
Authorized Official - Last Name:PETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS/LP
Authorized Official - Phone:507-452-7292
Mailing Address - Street 1:66 E. 3RD STREET #201
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987
Mailing Address - Country:US
Mailing Address - Phone:507-462-7292
Mailing Address - Fax:507-457-9887
Practice Address - Street 1:66 E. 3RD STREET #201
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987
Practice Address - Country:US
Practice Address - Phone:507-462-7292
Practice Address - Fax:507-457-9887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4439103T00000X
MNLP4392103T00000X
MNLP1219103T00000X
MNLP3132103T00000X
MNLP0177103T00000X
MN8677104100000X
MN8882104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14809OtherHEALTHPARTNERS
01015397OtherPREFERRED ONE
57490FAOtherBCBS
38076T0OtherBCBS
MNE341OtherUCARE
C01866Medicare ID - Type Unspecified