Healthcare Provider Details

I. General information

NPI: 1497896641
Provider Name (Legal Business Name): COUNTY OF SHAWANO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 LAKELAND RD
SHAWANO WI
54166
US

IV. Provider business mailing address

504 LAKELAND RD
SHAWANO WI
54166
US

V. Phone/Fax

Practice location:
  • Phone: 715-526-5547
  • Fax: 715-526-5542
Mailing address:
  • Phone: 715-526-5547
  • Fax: 715-526-5542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1831
License Number StateWI

VIII. Authorized Official

Name: MS. BARBARA LARSON-HERBER
Title or Position: EXECUTIVE PROGRAM DIRECTOR
Credential:
Phone: 715-526-5547