Healthcare Provider Details

I. General information

NPI: 1447425145
Provider Name (Legal Business Name): MARY BERNADETTE BARNEY CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N2150 KESAEHKAHTEK
GRESHAM WI
54128
US

IV. Provider business mailing address

N2150 KESAEHKAHTEK RD
GRESHAM WI
54128-9602
US

V. Phone/Fax

Practice location:
  • Phone: 715-799-3835
  • Fax: 715-799-3836
Mailing address:
  • Phone: 715-799-3835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1715
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier39367500
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: