Provider Demographics
NPI:1457807091
Name:QAM
Entity Type:Organization
Organization Name:QAM
Other - Org Name:RACINE COMPREHENSIVE TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-598-1392
Mailing Address - Street 1:5735 DURAND AVE
Mailing Address - Street 2:A
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-5011
Mailing Address - Country:US
Mailing Address - Phone:262-598-1392
Mailing Address - Fax:262-598-1395
Practice Address - Street 1:5735 DURAND AVE
Practice Address - Street 2:A
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-5011
Practice Address - Country:US
Practice Address - Phone:262-598-1392
Practice Address - Fax:262-598-1395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15532-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========Medicaid