Provider Demographics
NPI:1366556359
Name:BLUE WATERS FAMILY COUNSELING, S.C.
Entity type:Organization
Organization Name:BLUE WATERS FAMILY COUNSELING, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LCSW JD
Authorized Official - Phone:920-683-3911
Mailing Address - Street 1:2215 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4847
Mailing Address - Country:US
Mailing Address - Phone:920-683-3911
Mailing Address - Fax:920-683-3411
Practice Address - Street 1:2215 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4847
Practice Address - Country:US
Practice Address - Phone:920-683-3911
Practice Address - Fax:920-683-3411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42217300Medicaid
WI42217300Medicaid