Healthcare Provider Details

I. General information

NPI: 1376650499
Provider Name (Legal Business Name): FOREST COUNTY POTAWATOMI HEALTH & WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 MISH KO SWEN DR
CRANDON WI
54520-8631
US

IV. Provider business mailing address

PO BOX 396 8201 MISH KO SWEN DRIVE
CRANDON WI
54520-0396
US

V. Phone/Fax

Practice location:
  • Phone: 715-478-4300
  • Fax: 715-478-4490
Mailing address:
  • Phone: 715-478-4300
  • Fax: 715-478-4490

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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. NED DANIELS
Title or Position: TRIBAL CHAIRMAN
Credential:
Phone: 715-478-4824