Healthcare Provider Details

I. General information

NPI: 1942063482
Provider Name (Legal Business Name): MENTAL HEALTH ON PRAIRIE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2797 PRAIRIE AVE STE 22
BELOIT WI
53511-2288
US

IV. Provider business mailing address

2797 PRAIRIE AVE STE 22
BELOIT WI
53511-2288
US

V. Phone/Fax

Practice location:
  • Phone: 608-481-2330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: FAITH MATTISON
Title or Position: OWNER, LCSW
Credential:
Phone: 608-481-2330