Provider Demographics
NPI:1750409934
Name:NORTHWEST COUNSELING & GUIDANCE CLINIC
Entity type:Organization
Organization Name:NORTHWEST COUNSELING & GUIDANCE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAURER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-349-7069
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-0309
Mailing Address - Country:US
Mailing Address - Phone:715-349-7069
Mailing Address - Fax:888-625-8634
Practice Address - Street 1:2916 BORHAM AVE
Practice Address - Street 2:STE A
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-5099
Practice Address - Country:US
Practice Address - Phone:715-997-9486
Practice Address - Fax:888-625-8634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2404261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN85575OtherPREFERRED ONE
MN42626OtherHEALTH PARTNERS
WI7H956NOOtherBCBS OF MN
WI43007300Medicaid