Basic Information
| Provider Information | |||||||||
| NPI: | 1104930866 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF ADAMS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADAMS COUNTY HEALTH & HUMAN SERVICES DEPARTMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 108 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | FRIENDSHIP | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539349443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083394505 | ||||||||
| FaxNumber: | 6083394593 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | FRIENDSHIP | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539349443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083394505 | ||||||||
| FaxNumber: | 6083394593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 10/30/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CABLE | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | DIR OF HEALTH & HUMAN SVS | ||||||||
| AuthorizedOfficialTelephone: | 6083394505 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 1253 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 43109000 | 05 | WI | MEDICAID | 43079900 | 05 | WI | MEDICAID | 43070000 | 05 | WI | MEDICAID | 42117800 | 05 | WI | MEDICAID |