MEDICARE: CATHOLIC CHARITIES OF THE DIOCESE OF LACROSSE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	103T00000X	Psychologist
3	104100000X	Social Worker
4	106H00000X	Marriage & Family Therapist
5	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558393009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CATHOLIC CHARITIES OF THE DIOCESE OF LACROSSE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1127
Second Line	:
City	:	SHEBOYGAN
State	:	WI
Zip	:	53082-1127
Country	:	US
Telephone Number	:	920-457-6750
Fax Number	:	920-457-8350

Provider Business Practice Location Address
First Line	:	3710 EAST AVE S
Second Line	:
City	:	LA CROSSE
State	:	WI
Zip	:	54602-0266
Country	:	US
Telephone Number	:	608-782-0710
Fax Number	:	608-782-0702

Authorized Official
Title or Position	:	DEACON, EXECUTIVE DIRECTOR
Name	:	MR. RICHARD SAGE
Credential	:	M.A.
Telephone Number	:	608-782-0710

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	04/20/2008

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