Basic Information
| Provider Information | |||||||||
| NPI: | 1295974285 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOOR COUNTY DEPT OF COMMUNITY PROGRAMS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 NEBRASKA STREET | ||||||||
| Address2: | |||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542352249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207462345 | ||||||||
| FaxNumber: | 9207462439 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 NEBRASKA ST | ||||||||
| Address2: | |||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542352225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207462345 | ||||||||
| FaxNumber: | 9207462439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2009 | ||||||||
| LastUpdateDate: | 02/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | KREBSBACH | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9207462345 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | ICS, CSAC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1283 | WI | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 32976600 | 05 | WI | MEDICAID |