Healthcare Provider Details

I. General information

NPI: 1124094263
Provider Name (Legal Business Name): SSM HEALTH TREATMENT AND RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 JEFFERSON ST
BARABOO WI
53913-1505
US

IV. Provider business mailing address

1510 JEFFERSON ST
BARABOO WI
53913-1505
US

V. Phone/Fax

Practice location:
  • Phone: 608-356-1533
  • Fax:
Mailing address:
  • Phone: 608-356-1533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TROY L WALKER
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 608-356-1400