Basic Information
Provider Information | |||||||||
NPI: | 1760902191 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AGNESIAN HEALTHCARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AGNESIAN BEYOND BOUNDARIES OF AUTISM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 40 CAMELOT DR | ||||||||
Address2: |   | ||||||||
City: | FOND DU LAC | ||||||||
State: | WI | ||||||||
PostalCode: | 549358049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9209078201 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 40 CAMELOT DR | ||||||||
Address2: |   | ||||||||
City: | FOND DU LAC | ||||||||
State: | WI | ||||||||
PostalCode: | 549358049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9209078201 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2017 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHMITZ | ||||||||
AuthorizedOfficialFirstName: | BONNIE | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | VP & CFO | ||||||||
AuthorizedOfficialTelephone: | 9209264480 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 2226 | WI | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.