Basic Information
| Provider Information | |||||||||
| NPI: | 1780610923 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY SERVICE ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | D/B/A PAUQUETTE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 301 | ||||||||
| Address2: | 2901 HUNTERS TRAIL | ||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539013403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087425518 | ||||||||
| FaxNumber: | 6087424087 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 HUNTERS TRL | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539013403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087425518 | ||||||||
| FaxNumber: | 6087424087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 11/07/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEVENS | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING DEPT/BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6085245151 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 2149 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 292394 | 01 | WI | VALUE OPTIONS | OTHER | W010102 | 01 | WI | TRICARE/CHAMPUS | OTHER | 501113 | 01 | WI | DEAN HEALTH PLAN | OTHER | CD8222 | 01 | WI | RAILROAD MEDICARE | OTHER |