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General NPI Number Information
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NPI Number | 1700817657
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Entity Type | Organization
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Legal Business Name | AGNESIAN HEALTHCARE
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Dates
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Enumeration Date | 07/06/2006
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Last Update Date | 09/04/2007
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Provider Practice Location Address
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Address Line | 200 FRONT ST SUITE 3D
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City | BEAVER DAM
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State | WI
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Zip | 53916-1667
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Country | US
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Telephone | 920-885-2780
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Fax | 920-885-2788
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Provider Business Mailing Address
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Address Line | 200 FRONT ST SUITE 3D
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City | BEAVER DAM
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State | WI
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Zip | 53916-1667
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Country | US
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Telephone | 920-885-2780
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Fax | 920-885-2788
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | DR. JAMES SALASEK
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Credential | PHD
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Telephone | 920-885-2780
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 1753
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License Number State | WI
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