Provider Demographics
NPI:1821196171
Name:NORTHERN LIGHTS PSYCHIATRIC SERVICES SC
Entity Type:Organization
Organization Name:NORTHERN LIGHTS PSYCHIATRIC SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-838-9173
Mailing Address - Street 1:826 S HASTINGS WAY
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3426
Mailing Address - Country:US
Mailing Address - Phone:715-838-9173
Mailing Address - Fax:715-834-3174
Practice Address - Street 1:826 S HASTINGS WAY
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3426
Practice Address - Country:US
Practice Address - Phone:715-838-9173
Practice Address - Fax:715-834-3174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31815200Medicaid
F28927Medicare UPIN