Basic Information
| Provider Information | |||||||||
| NPI: | 1881602761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THUNDER | ||||||||
| FirstName: | BETTY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ADVANCED PRACTICE SO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOW | ||||||||
| OtherFirstName: | BETTY | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 396 | ||||||||
| Address2: | 5409 EVERYBODY'S ROAD FOREST COUNTY POTAWATOMI HEALTH | ||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154784300 | ||||||||
| FaxNumber: | 7154784490 | ||||||||
| Practice Location | |||||||||
| Address1: | 5409 EVERYBODY'S ROAD | ||||||||
| Address2: | FOREST COUNTY POTAWATOMI HEALTH & WELLNESS CENTER | ||||||||
| City: | CRANDON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154784300 | ||||||||
| FaxNumber: | 7154784490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 677121 | WI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 66628 | 01 | WI | SECURITY HEALTH PLAN | OTHER | 39700200 | 05 | WI | MEDICAID |