Provider Demographics
NPI:1306965033
Name:NORTHWEST JOURNEY - ELLSWORTH
Entity type:Organization
Organization Name:NORTHWEST JOURNEY - ELLSWORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:KALAMBOKIDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-327-4402
Mailing Address - Street 1:N6096 530TH ST
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:54011-5107
Mailing Address - Country:US
Mailing Address - Phone:715-273-0203
Mailing Address - Fax:715-273-0344
Practice Address - Street 1:N6096 530TH ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:WI
Practice Address - Zip Code:54011-5107
Practice Address - Country:US
Practice Address - Phone:715-273-0203
Practice Address - Fax:715-273-0344
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST COUNSELING AND GUIDANCE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-27
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2326261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43006700Medicaid
MN7H956NOOtherBCBS OF MN
MN42626OtherHEALTH PARTNERS
WI1306965033OtherHUMANA
MN85575OtherPREFERRED ONE
WI1306965033OtherVALUE OPTIONS