MEDICARE: WASHINGTON COUNTY WISCONSIN

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor
3	103T00000X	Psychologist
4	103TC0700X	Clinical Psychologist
5	251S00000X	Community/Behavioral Health Agency	1968	WI

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609801778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASHINGTON COUNTY WISCONSIN

Provider Business Mailing Address
First Line	:	333 E. WASHINGTON STREET
Second Line	:	SUITE 2100
City	:	WEST BEND
State	:	WI
Zip	:	53095-2585
Country	:	US
Telephone Number	:	262-335-4583
Fax Number	:	262-335-6827

Provider Business Practice Location Address
First Line	:	333 E. WASHINGTON STREET
Second Line	:	SUITE 2100
City	:	WEST BEND
State	:	WI
Zip	:	53095-2585
Country	:	US
Telephone Number	:	262-335-4583
Fax Number	:	262-335-6827

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	ERIC DIAMOND
Credential	:
Telephone Number	:	262-335-4591

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	08/11/2015

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Directions to “WASHINGTON COUNTY WISCONSIN ” Practice Location

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