Provider Demographics
NPI:1306123070
Name:COULEE COUNCIL ON ADDICTIONS
Entity type:Organization
Organization Name:COULEE COUNCIL ON ADDICTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-784-4177
Mailing Address - Street 1:921 WEST AVE S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4745
Mailing Address - Country:US
Mailing Address - Phone:608-784-4177
Mailing Address - Fax:608-784-6302
Practice Address - Street 1:921 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4745
Practice Address - Country:US
Practice Address - Phone:608-784-4177
Practice Address - Fax:608-784-6302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1240251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42230400Medicaid