Healthcare Provider Details

I. General information

NPI: 1275525925
Provider Name (Legal Business Name): FAMILY SERVICES OF NORTHEAST WISCONSIN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 06/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 APPLETON RD
MENASHA WI
54952-1110
US

IV. Provider business mailing address

1810 APPLETON RD
MENASHA WI
54952-1110
US

V. Phone/Fax

Practice location:
  • Phone: 920-739-4226
  • Fax: 920-739-7639
Mailing address:
  • Phone: 920-739-4226
  • Fax: 920-739-7639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1333
License Number StateWI

VIII. Authorized Official

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