Provider Demographics
NPI:1861885014
Name:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Entity type:Organization
Organization Name:LAC DU FLAMBEAU BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HUMAN SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ERNST
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,LMSW-ACP
Authorized Official - Phone:715-588-1511
Mailing Address - Street 1:533 PEACE PIPE RD
Mailing Address - Street 2:PO BOC 189
Mailing Address - City:LAC DU FLAMBEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54538-9123
Mailing Address - Country:US
Mailing Address - Phone:715-588-1511
Mailing Address - Fax:
Practice Address - Street 1:533 PEACE PIPE RD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-9123
Practice Address - Country:US
Practice Address - Phone:715-588-1511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3071251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health