Basic Information
| Provider Information | |||||||||
| NPI: | 1609867001 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF OZAUKEE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OZAUKEE COUNTY HUMAN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 121 W MAIN ST | ||||||||
| Address2: | DEPARTMENT HUMAN SERVICES | ||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530741813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622848200 | ||||||||
| FaxNumber: | 2622848104 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 W MAIN ST | ||||||||
| Address2: | DEPARTMENT HUMAN SERVICES | ||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530741813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622848200 | ||||||||
| FaxNumber: | 2622848104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 07/22/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAPPEN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2622848200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 42138800 | 05 | WI | MEDICAID |