Basic Information
| Provider Information | |||||||||
| NPI: | 1487691697 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF JUNEAU | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | JUNEAU COUNTY DEPARTMENT OF HUMAN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HICKORY STREET | ||||||||
| Address2: | JUNEAU COUNTY HUMAN SERVICES | ||||||||
| City: | MAUSTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539481320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088472400 | ||||||||
| FaxNumber: | 6088479599 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HICKORY STREET | ||||||||
| Address2: | JUNEAU COUNTY HUMAN SERVICES | ||||||||
| City: | MAUSTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539481320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088472400 | ||||||||
| FaxNumber: | 6088479599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | BUCHHOLZ | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6088472400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 1487691697 | 05 | WI | MEDICAID |