Provider Demographics
NPI:1851570022
Name:COOPERATIVE EDUCATIONAL SERVICE AGENCY #12
Entity Type:Organization
Organization Name:COOPERATIVE EDUCATIONAL SERVICE AGENCY #12
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SPECIAL EDUCATION
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-682-2363
Mailing Address - Street 1:618 BEASER AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-2751
Mailing Address - Country:US
Mailing Address - Phone:715-682-2363
Mailing Address - Fax:715-682-7244
Practice Address - Street 1:618 BEASER AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-2751
Practice Address - Country:US
Practice Address - Phone:715-682-2363
Practice Address - Fax:715-682-7244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44200400Medicaid