Provider Demographics
NPI:1013153139
Name:INNES, WILLIAM OWEN (BSW)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:OWEN
Last Name:INNES
Suffix:
Gender:M
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 WEST AVE N
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-1406
Mailing Address - Country:US
Mailing Address - Phone:608-786-2135
Mailing Address - Fax:
Practice Address - Street 1:1407 SAINT ANDREW ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-3301
Practice Address - Country:US
Practice Address - Phone:608-785-5765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI504-120171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator