Basic Information
| Provider Information | |||||||||
| NPI: | 1659680718 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HO CHUNK NATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HOUSE OF WELLNESS BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | N6520 LUMBERJACK GUY RD | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546155405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152849851 | ||||||||
| FaxNumber: | 7152845150 | ||||||||
| Practice Location | |||||||||
| Address1: | S2845 WHITE EAGLE RD | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539139064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083561251 | ||||||||
| FaxNumber: | 6083567122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2010 | ||||||||
| LastUpdateDate: | 03/27/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LUND | ||||||||
| AuthorizedOfficialFirstName: | LIZ | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER NETWORK MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7152849851 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HO CHUNK NATION | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 1413 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1413 | 01 | WI | STATE CERTIFICATION | OTHER |