Provider Demographics
NPI:1841463213
Name:WAUSHARA COUNTY
Entity type:Organization
Organization Name:WAUSHARA COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:F
Authorized Official - Last Name:THEYEL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LCSW
Authorized Official - Phone:920-787-6550
Mailing Address - Street 1:PO BOX 1230
Mailing Address - Street 2:230 W. PARK STREET
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-1230
Mailing Address - Country:US
Mailing Address - Phone:920-787-6550
Mailing Address - Fax:920-787-0421
Practice Address - Street 1:230 PARK ST
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-9031
Practice Address - Country:US
Practice Address - Phone:920-787-6550
Practice Address - Fax:920-787-0421
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAUSHARA COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1980251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42140600Medicaid
WI84306Medicare UPIN