=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467168898
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CGH HOLDINGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2023
-----------------------------------------------------
Last Update Date | 01/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1707 HILLSDALE RD
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54703-2537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-559-7693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1707 HILLSDALE RD
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54703-2537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-559-7693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ONWER
-----------------------------------------------------
Name | MRS. GINA HAUPT
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 715-559-7693
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------