Healthcare Provider Details

I. General information

NPI: 1770985467
Provider Name (Legal Business Name): NORTHWEST COUNSELING & GUIDANCE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16092 HIGHWAY 63
HAYWARD WI
54843-9775
US

IV. Provider business mailing address

203 UNITED WAY
FREDERIC WI
54837-8938
US

V. Phone/Fax

Practice location:
  • Phone: 715-699-1241
  • Fax: 715-699-1243
Mailing address:
  • Phone: 715-327-4322
  • Fax: 715-327-8509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number3049
License Number StateWI

VIII. Authorized Official

Name: JACKIE J MAURER
Title or Position: BILLING OFFICE SUPERVISOR
Credential:
Phone: 715-327-4322