Provider Demographics
NPI:1902923568
Name:NORTHWEST COUNSELING AND GUIDANCE CLINIC- SIREN DAY TREATMENT
Entity Type:Organization
Organization Name:NORTHWEST COUNSELING AND GUIDANCE CLINIC- SIREN DAY TREATMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-349-7069
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-0309
Mailing Address - Country:US
Mailing Address - Phone:715-349-7069
Mailing Address - Fax:888-625-8634
Practice Address - Street 1:24996 ST RD 35
Practice Address - Street 2:
Practice Address - City:SIREN
Practice Address - State:WI
Practice Address - Zip Code:54872-9239
Practice Address - Country:US
Practice Address - Phone:715-349-7069
Practice Address - Fax:888-625-8634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2290261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HUMANAOtherHUMANA
MN42626OtherHEALTH PARTNERS
WI43004000Medicaid
VALUE OPTIONSOtherVALUE OPTIONS
MN7H956NOOtherBCBS OF MN
MNPREFERRED ONEOtherPREFERRED ONE