Healthcare Provider Details

I. General information

NPI: 1457559262
Provider Name (Legal Business Name): WILLOWGLEN HEIN FOSTER CARE GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 HEIN AVE
PLYMOUTH WI
53073-2526
US

IV. Provider business mailing address

207 HEIN AVE
PLYMOUTH WI
53073-2526
US

V. Phone/Fax

Practice location:
  • Phone: 920-893-5132
  • Fax:
Mailing address:
  • Phone: 920-893-5132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number1005423
License Number StateWI

VIII. Authorized Official

Name: JAYA SINGH
Title or Position: DIRECTOR RESIDENTIAL SERVICES
Credential: PH.D.
Phone: 414-527-6970