Healthcare Provider Details

I. General information

NPI: 1154675924
Provider Name (Legal Business Name): NORTHSHORE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N 6TH ST
SHEBOYGAN WI
53081-4113
US

IV. Provider business mailing address

805 N 6TH ST
SHEBOYGAN WI
53081-4113
US

V. Phone/Fax

Practice location:
  • Phone: 920-457-8866
  • Fax: 920-457-8867
Mailing address:
  • Phone: 920-457-8866
  • Fax: 920-457-8867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA A BRINKMAN
Title or Position: CLINIC DIRECTOR
Credential: LCSW
Phone: 920-457-8866