Basic Information
| Provider Information | |||||||||
| NPI: | 1114995164 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOOD SHEPHERD HOME, LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOOD SHEPHERD REHABILITATION AGENCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 958 FOOTE STREET | ||||||||
| Address2: | |||||||||
| City: | SEYMOUR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208337796 | ||||||||
| FaxNumber: | 9208332220 | ||||||||
| Practice Location | |||||||||
| Address1: | 958 FOOTE STREET | ||||||||
| Address2: | |||||||||
| City: | SEYMOUR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208337796 | ||||||||
| FaxNumber: | 9208332220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 01/12/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAPTAIN | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9208336856 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN NHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2659 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | 2659 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | 2659 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 41814400 | 05 | WI | MEDICAID |