Basic Information
| Provider Information | |||||||||
| NPI: | 1740621044 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVER'S SHORE CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CRC HEALTHCARE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3707 N RICHARDS ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149677006 | ||||||||
| FaxNumber: | 4149677020 | ||||||||
| Practice Location | |||||||||
| Address1: | 3707 N RICHARDS ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149677006 | ||||||||
| FaxNumber: | 4149677020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2013 | ||||||||
| LastUpdateDate: | 07/15/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DANOSKI | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4149677006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CSAC, ICS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1643 | WI | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | DJKF54 | 01 | WI | TAXONOMY NUMBER - 261QM0801X | OTHER |