Healthcare Provider Details

I. General information

NPI: 1689983157
Provider Name (Legal Business Name): NORTHWEST JOURNEY - WAUPACA COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E MAIN ST
WEYAUWEGA WI
54983-8938
US

IV. Provider business mailing address

310 E MAIN ST
WEYAUWEGA WI
54983-8938
US

V. Phone/Fax

Practice location:
  • Phone: 715-867-4744
  • Fax: 920-867-4213
Mailing address:
  • Phone: 715-867-4744
  • Fax: 920-867-4213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number2922
License Number StateWI

VIII. Authorized Official

Name: NICK KALAMBOKISIS
Title or Position: CFO
Credential:
Phone: 715-327-4322