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General NPI Number Information
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NPI Number | 1942063482
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Entity Type | Organization
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Legal Business Name | MENTAL HEALTH ON PRAIRIE
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Dates
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Enumeration Date | 02/06/2024
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Last Update Date | 02/06/2024
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Provider Practice Location Address
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Address Line | 2797 PRAIRIE AVE STE 22
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City | BELOIT
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State | WI
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Zip | 53511-2288
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Country | US
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Telephone | 608-481-2330
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Fax |
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Provider Business Mailing Address
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Address Line | 2797 PRAIRIE AVE STE 22
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City | BELOIT
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State | WI
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Zip | 53511-2288
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER, LCSW
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Name | FAITH MATTISON
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Credential |
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Telephone | 608-481-2330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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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 |
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License Number State |
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