Provider Demographics
NPI:1295113587
Name:ST. COLETTA OF WISCONSIN, INC.
Entity type:Organization
Organization Name:ST. COLETTA OF WISCONSIN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF DAY PROGRAMS & SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:920-674-8219
Mailing Address - Street 1:N4637 COUNTY ROAD Y
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-9720
Mailing Address - Country:US
Mailing Address - Phone:920-674-4330
Mailing Address - Fax:920-674-8422
Practice Address - Street 1:N4637 COUNTY ROAD Y
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-9720
Practice Address - Country:US
Practice Address - Phone:920-674-4330
Practice Address - Fax:920-674-8422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILPROVISIONAL CERTIFIC251C00000X
251E00000X, 261QA0600X
IL199800003C320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities