Healthcare Provider Details

I. General information

NPI: 1053964783
Provider Name (Legal Business Name): MATTHEW MACHNIK MSW, APSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W3272 WOLF RIVER DRIVE
KESHENA WI
54135-9202
US

IV. Provider business mailing address

P.O. BOX 280
KESHENA WI
54135-0280
US

V. Phone/Fax

Practice location:
  • Phone: 715-799-3861
  • Fax: 715-799-3517
Mailing address:
  • Phone: 715-799-3861
  • Fax: 715-799-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number131580-121
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: