Healthcare Provider Details

I. General information

NPI: 1902923568
Provider Name (Legal Business Name): NORTHWEST COUNSELING AND GUIDANCE CLINIC- SIREN DAY TREATMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24996 ST RD 35
SIREN WI
54872-9239
US

IV. Provider business mailing address

PO BOX 309
SIREN WI
54872-0309
US

V. Phone/Fax

Practice location:
  • Phone: 715-349-7069
  • Fax: 888-625-8634
Mailing address:
  • Phone: 715-349-7069
  • Fax: 888-625-8634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number2290
License Number StateWI

VIII. Authorized Official

Name: JACKIE MAURER
Title or Position: OFFICE SUPERVISOR
Credential:
Phone: 715-349-7069