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General NPI Number Information
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NPI Number | 1225155245
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Entity Type | Organization
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Legal Business Name | FAMILY SERVICES OF NORTHEAST WISCONSIN, INC.
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Dates
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Enumeration Date | 03/23/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3430 SPIRIT WAY
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City | GREEN BAY
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State | WI
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Zip | 54304-5687
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Country | US
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Telephone | 920-330-0339
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Fax | 920-330-9060
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Provider Business Mailing Address
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Address Line | 300 CROOKS ST
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City | GREEN BAY
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State | WI
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Zip | 54301-4527
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Country | US
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Telephone | 920-436-6800
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Fax |
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Authorized Official
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Title or Position | PRESIDENT-CEO
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Name | THOMAS MARTIN
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Credential |
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Telephone | 920-436-6800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number | 1005260
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License Number State | WI
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