Basic Information
| Provider Information | |||||||||
| NPI: | 1255562344 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ONEIDA NATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KA NI KUHL YO FAMILY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 365 | ||||||||
| Address2: | |||||||||
| City: | ONEIDA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204903790 | ||||||||
| FaxNumber: | 9204903845 | ||||||||
| Practice Location | |||||||||
| Address1: | 2640 WEST POINT RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204903790 | ||||||||
| FaxNumber: | 9204903845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2009 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KRIESCHER | ||||||||
| AuthorizedOfficialFirstName: | MARI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9204903737 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MS, LPC, CSAC, ICS | ||||||||
| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 15395132 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 7211123 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.