=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184896920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S SERVICE SOCIETY OF WISCONSIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2008
-----------------------------------------------------
Last Update Date | 04/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2004 HIGHLAND AVE STE M
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54701-4389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-835-5915
-----------------------------------------------------
Fax | 715-835-8112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2004 HIGHLAND AVE STE M
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54701-4389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-835-5915
-----------------------------------------------------
Fax | 715-835-8112
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AREA SUPERVISOR
-----------------------------------------------------
Name | MARNIE HERSRUD
-----------------------------------------------------
Credential | MSW, LCSW
-----------------------------------------------------
Telephone | 715-835-5915
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 1186
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------