Provider Demographics
NPI:1891126751
Name:PINE VALLEY RESIDENTIAL SERVICES
Entity Type:Organization
Organization Name:PINE VALLEY RESIDENTIAL SERVICES
Other - Org Name:PINE VALLEY SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO / OWNER MEMBER LLC
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-847-7575
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-0359
Mailing Address - Country:US
Mailing Address - Phone:608-847-7575
Mailing Address - Fax:608-847-3096
Practice Address - Street 1:124 GRAYSIDE AVE
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-1913
Practice Address - Country:US
Practice Address - Phone:608-847-7575
Practice Address - Fax:608-847-3096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-03
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7163-123251B00000X, 251S00000X
WIAFH320800000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1205830965Medicaid