Provider Demographics
NPI:1881602761
Name:THUNDER, BETTY S (ADVANCED PRACTICE SO)
Entity type:Individual
Prefix:MS
First Name:BETTY
Middle Name:S
Last Name:THUNDER
Suffix:
Gender:F
Credentials:ADVANCED PRACTICE SO
Other - Prefix:MS
Other - First Name:BETTY
Other - Middle Name:S
Other - Last Name:BOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APSW
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:5409 EVERYBODY'S ROAD FOREST COUNTY POTAWATOMI HEALTH
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520
Mailing Address - Country:US
Mailing Address - Phone:715-478-4300
Mailing Address - Fax:715-478-4490
Practice Address - Street 1:5409 EVERYBODY'S ROAD
Practice Address - Street 2:FOREST COUNTY POTAWATOMI HEALTH & WELLNESS CENTER
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520
Practice Address - Country:US
Practice Address - Phone:715-478-4300
Practice Address - Fax:715-478-4490
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI677121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI66628OtherSECURITY HEALTH PLAN
WI39700200Medicaid