Provider Demographics
NPI:1912181538
Name:ST. CROIX PSYCHOLOGICAL CLINIC
Entity Type:Organization
Organization Name:ST. CROIX PSYCHOLOGICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:WI LIC. PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:HAMANN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:715-425-7031
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-0425
Mailing Address - Country:US
Mailing Address - Phone:715-425-7031
Mailing Address - Fax:715-425-1055
Practice Address - Street 1:258 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-3236
Practice Address - Country:US
Practice Address - Phone:715-425-7031
Practice Address - Fax:715-425-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI371-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39062200Medicaid
1427168079OtherNPI
WI44560Medicare PIN