Provider Demographics
NPI:1982821575
Name:NORTHWEST COUNSELING AND GUIDANCE - NORTHWEST JOURNEY - SUPERIOR
Entity Type:Organization
Organization Name:NORTHWEST COUNSELING AND GUIDANCE - NORTHWEST JOURNEY - SUPERIOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:KALAMBOKIDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-327-4402
Mailing Address - Street 1:1412 E SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:ID
Mailing Address - Zip Code:54880
Mailing Address - Country:US
Mailing Address - Phone:715-395-3805
Mailing Address - Fax:715-424-5720
Practice Address - Street 1:1419 HILL AVE STE B
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-1951
Practice Address - Country:US
Practice Address - Phone:715-395-3805
Practice Address - Fax:715-424-5720
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST COUNSELING AND GUIDANCE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-18
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2074261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HUMANAOtherHUMANA
MN42626OtherHEALTH PARTNERS
VALUE OPTIONSOtherVALUE OPTIONS
MN7H956NOOtherBCBS OF MN
MN85575OtherPREFERRED ONE
WI43004700Medicaid