Basic Information
| Provider Information | |||||||||
| NPI: | 1003079708 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIPFORD | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 E LA CROSSE ST. | ||||||||
| Address2: | JUNEAU COUNTY HUMAN SERVICES | ||||||||
| City: | MAUSTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539482101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088472400 | ||||||||
| FaxNumber: | 6088479599 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 E LA CROSSE ST. | ||||||||
| Address2: | JUNEAU COUNTY HUMAN SERVICES | ||||||||
| City: | MAUSTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539482101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088472400 | ||||||||
| FaxNumber: | 6088479599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 06/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 302375 | MN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 15413-131 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1003079708 | 05 | WI | MEDICAID |