Provider Demographics
NPI:1295175065
Name:BETHANY CHRISTIAN SERVICES
Entity type:Organization
Organization Name:BETHANY CHRISTIAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:STOUTMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-224-7429
Mailing Address - Street 1:1331 CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-5705
Mailing Address - Country:US
Mailing Address - Phone:262-547-6557
Mailing Address - Fax:262-547-3644
Practice Address - Street 1:1331 CAPITOL DR
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-5705
Practice Address - Country:US
Practice Address - Phone:262-547-6557
Practice Address - Fax:262-547-3644
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BETHANY CHRISTIAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-26
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI205-121104100000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty