Provider Demographics
NPI:1144466608
Name:FOND DU LAC PSYCHIATRY LLC
Entity type:Organization
Organization Name:FOND DU LAC PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:JUNIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:920-923-9054
Mailing Address - Street 1:1020 S MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-6102
Mailing Address - Country:US
Mailing Address - Phone:920-923-9054
Mailing Address - Fax:920-322-9193
Practice Address - Street 1:1020 S MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-6102
Practice Address - Country:US
Practice Address - Phone:920-923-9054
Practice Address - Fax:920-322-9193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32668-020261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31769900Medicaid
WI31769900Medicaid