Healthcare Provider Details

I. General information

NPI: 1386035913
Provider Name (Legal Business Name): MICHAEL JAMES YORK SAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2015
Last Update Date: 02/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 PRAIRIE AVE
BELOIT WI
53511-2648
US

IV. Provider business mailing address

2240 PRAIRIE AVE
BELOIT WI
53511-2648
US

V. Phone/Fax

Practice location:
  • Phone: 608-361-7200
  • Fax: 608-361-7201
Mailing address:
  • Phone: 608-361-7200
  • Fax: 608-361-7201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15955-131
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: