Basic Information
| Provider Information | |||||||||
| NPI: | 1285641647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIRKUS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| OtherLastName: | WIRKUS | ||||||||
| OtherFirstName: | JOHN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | CADC3 | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 111 WEST ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CREEK | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530389503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206993703 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16535 W BLUEMOUND RD | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530055936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625423255 | ||||||||
| FaxNumber: | 2628216180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1006 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.