Healthcare Provider Details

I. General information

NPI: 1295783124
Provider Name (Legal Business Name): COUNTY OF TREMPEALEAU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18425 DODGE ST
WHITEHALL WI
54773-8444
US

IV. Provider business mailing address

W20410 STATE ROAD 121
WHITEHALL WI
54773-9147
US

V. Phone/Fax

Practice location:
  • Phone: 715-538-4518
  • Fax: 715-538-4535
Mailing address:
  • Phone: 715-538-4312
  • Fax: 715-538-2426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberCBRF474
License Number StateWI

VIII. Authorized Official

Name: JERRY DEETZ
Title or Position: EXECUTIVE DIRECTOR
Credential: N.H.A.
Phone: 715-538-4312