Basic Information
| Provider Information | |||||||||
| NPI: | 1205825130 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ONEIDA NATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KA NI KUHLI YO FAMILY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 365 | ||||||||
| Address2: | |||||||||
| City: | ONEIDA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541550365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204903790 | ||||||||
| FaxNumber: | 9204903883 | ||||||||
| Practice Location | |||||||||
| Address1: | 2640 W POINT RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543041344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204903790 | ||||||||
| FaxNumber: | 9204903737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KRIESCHER | ||||||||
| AuthorizedOfficialFirstName: | MARI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BEHAVIORAL HEALTH MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9204903790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MS LPC CSAC ICS | ||||||||
| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 42189100 | 05 | WI | MEDICAID |