Basic Information
| Provider Information | |||||||||
| NPI: | 1376650499 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOREST COUNTY POTAWATOMI HEALTH & WELLNESS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 396 | ||||||||
| Address2: | 8201 MISH KO SWEN DRIVE | ||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545200396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154784300 | ||||||||
| FaxNumber: | 7154784490 | ||||||||
| Practice Location | |||||||||
| Address1: | 8201 MISH KO SWEN DR | ||||||||
| Address2: | |||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545208631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154784300 | ||||||||
| FaxNumber: | 7154784490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | DANIELS | ||||||||
| AuthorizedOfficialFirstName: | NED | ||||||||
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| AuthorizedOfficialTitleorPosition: | TRIBAL CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 7154784824 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 42182600 | 05 | WI | MEDICAID |