Basic Information
| Provider Information | |||||||||
| NPI: | 1558518076 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOOR COUNTY DEPARTMENT OF COMMUNITY PROGRAMS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DOOR COUNTY COMMUNITY SUPPORT PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 421 NEBRASKA ST | ||||||||
| Address2: | |||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542352225 | ||||||||
| 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: | 08/27/2008 | ||||||||
| LastUpdateDate: | 08/27/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLORES | ||||||||
| AuthorizedOfficialFirstName: | SHERYL | ||||||||
| AuthorizedOfficialMiddleName: | FAYE | ||||||||
| AuthorizedOfficialTitleorPosition: | CSP COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9207462345 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DOOR COUNTY COMMUNITY SUPPORT PROGRAM | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1510-123 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39693300 | 05 | WI | MEDICAID |