Provider Demographics
NPI:1942063482
Name:MENTAL HEALTH ON PRAIRIE
Entity Type:Organization
Organization Name:MENTAL HEALTH ON PRAIRIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LCSW
Authorized Official - Prefix:
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-481-2330
Mailing Address - Street 1:2797 PRAIRIE AVE STE 22
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2288
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2797 PRAIRIE AVE STE 22
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2288
Practice Address - Country:US
Practice Address - Phone:608-481-2330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty