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General NPI Number Information
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NPI Number | 1639211469
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Entity Type | Organization
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Legal Business Name | FOX VALLEY MENTAL HEALTH, L.L.C.
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Dates
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Enumeration Date | 02/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2924 SCENIC DR
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City | OSHKOSH
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State | WI
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Zip | 54904-7641
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Country | US
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Telephone | 920-203-5742
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Fax |
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Provider Business Mailing Address
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Address Line | 2924 SCENIC DR
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City | OSHKOSH
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State | WI
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Zip | 54904-7641
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Country | US
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Telephone | 920-203-5742
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Fax |
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Authorized Official
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Title or Position | PSYCHIATRIST
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Name | DR. MARIA LUISA BALDOMERO-CONCEPCION
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Credential | M.D.
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Telephone | 920-203-5742
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 43051-020
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License Number State | WI
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