Basic Information
| Provider Information | |||||||||
| NPI: | 1609814367 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CEDAR CREEK FAMILY COUNSELING, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9910 W. LAYTON AVE. | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144274884 | ||||||||
| FaxNumber: | 4144274889 | ||||||||
| Practice Location | |||||||||
| Address1: | 9910 W. LAYTON AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144274884 | ||||||||
| FaxNumber: | 4144274889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 06/27/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEADE | ||||||||
| AuthorizedOfficialFirstName: | BUCKLEY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4144274884 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CADC III | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 42188500 | 05 | WI | MEDICAID |