=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821659624
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SALVATION ARMY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2019
-----------------------------------------------------
Last Update Date | 06/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | THE SALVATION ARMY RAY & JOAN KROC CENTER 1315 LIME KILN ROAD
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-544-4975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11315 W WATERTOWN PLANK RD
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53226-3412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-302-4300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM ACCOUNTABILITY DIRECTOR
-----------------------------------------------------
Name | JENNIFER L HENRY
-----------------------------------------------------
Credential | MSW, CSAC, ICS
-----------------------------------------------------
Telephone | 414-302-4300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 102L00000X
-----------------------------------------------------
Taxonomy Name | Psychoanalyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------