Healthcare Provider Details

I. General information

NPI: 1396936175
Provider Name (Legal Business Name): ECUMENICAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 CAPITOL DR SUITE 104
GREEN BAY WI
54303-2235
US

IV. Provider business mailing address

1540 CAPITOL DR SUITE 104
GREEN BAY WI
54303-2235
US

V. Phone/Fax

Practice location:
  • Phone: 920-491-9800
  • Fax: 920-491-9800
Mailing address:
  • Phone: 920-491-9800
  • Fax: 920-491-9800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number970057
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number104124
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number104124
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number970057
License Number StateWI

VIII. Authorized Official

Name: MR. JAMES PAUL HEIDER
Title or Position: LICENSED PSYCHOLOGIST
Credential: ED.S.
Phone: 920-491-9800