Healthcare Provider Details

I. General information

NPI: 1447423850
Provider Name (Legal Business Name): FAMILY SERVICES OF NORTHEAST WI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 RIVERSIDE DR
GREEN BAY WI
54301-2317
US

IV. Provider business mailing address

300 CROOKS ST PO BOX 22308
GREEN BAY WI
54301-4527
US

V. Phone/Fax

Practice location:
  • Phone: 920-436-4416
  • Fax:
Mailing address:
  • Phone: 920-436-6800
  • Fax: 920-437-3540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS E MARTIN
Title or Position: PRESIDENT
Credential:
Phone: 920-436-6800