=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366431173
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY OF KEWAUNEE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2005
-----------------------------------------------------
Last Update Date | 05/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 LINCOLN STREET
-----------------------------------------------------
City | KEWAUNEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54216-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-388-7030
-----------------------------------------------------
Fax | 920-388-7044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 810 LINCOLN STREET
-----------------------------------------------------
City | KEWAUNEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54216-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-388-7030
-----------------------------------------------------
Fax | 920-388-7044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. MELISSA M ANNOYE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-388-7030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 2288
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 1466
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------