Provider Demographics
NPI:1821479239
Name:MARQUETTE COUNTY DEPARTMENT OF HUMAN SERVICES-CLINICAL SERVICES
Entity Type:Organization
Organization Name:MARQUETTE COUNTY DEPARTMENT OF HUMAN SERVICES-CLINICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-297-3123
Mailing Address - Street 1:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:MONTELLO
Mailing Address - State:WI
Mailing Address - Zip Code:53949-0405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:480 UNDERWOOD AVE
Practice Address - Street 2:
Practice Address - City:MONTELLO
Practice Address - State:WI
Practice Address - Zip Code:53949-9248
Practice Address - Country:US
Practice Address - Phone:608-297-3124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43073900Medicaid
WI100028639Medicaid
WI32977271Medicaid