Provider Demographics
NPI:1770634370
Name:INNERCHANGE, INC.
Entity Type:Organization
Organization Name:INNERCHANGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:608-783-2186
Mailing Address - Street 1:1401 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-2858
Mailing Address - Country:US
Mailing Address - Phone:608-783-2186
Mailing Address - Fax:608-781-3405
Practice Address - Street 1:1401 MAIN ST
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-2858
Practice Address - Country:US
Practice Address - Phone:608-783-2186
Practice Address - Fax:608-781-3405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1435101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42165700Medicaid