Healthcare Provider Details

I. General information

NPI: 1700839644
Provider Name (Legal Business Name): NORTHLAND COMMUNITY SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 SPRING ST
WESTFIELD WI
53964-9068
US

IV. Provider business mailing address

161 SPRING ST PO BOX 248
WESTFIELD WI
53964-9068
US

V. Phone/Fax

Practice location:
  • Phone: 608-296-2139
  • Fax: 608-296-1590
Mailing address:
  • Phone: 608-296-2139
  • Fax: 608-296-1590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number822
License Number StateWI

VIII. Authorized Official

Name: JON S MATTHEW
Title or Position: DIRECTOR
Credential: PH.D
Phone: 608-296-2139