Provider Demographics
NPI:1104990530
Name:NORTHWEST COUNSELING & GUIDANCE CLINIC
Entity type:Organization
Organization Name:NORTHWEST COUNSELING & GUIDANCE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAURER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-327-4322
Mailing Address - Street 1:203 UNITED WAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-8938
Mailing Address - Country:US
Mailing Address - Phone:715-327-4322
Mailing Address - Fax:715-327-8509
Practice Address - Street 1:203 UNITED WAY DRIVE
Practice Address - Street 2:
Practice Address - City:FREDERIC
Practice Address - State:WI
Practice Address - Zip Code:54837-8938
Practice Address - Country:US
Practice Address - Phone:715-327-4402
Practice Address - Fax:715-327-4470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-18
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2254261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN42626OtherHEALTH PARTNERS
MN7H956NOOtherBCBS OF MN
MN85575OtherPREFERRED ONE
WI42214000Medicaid
MN42626OtherHEALTH PARTNERS