Provider Demographics
NPI:1386368041
Name:UNIVERSITY OF WISCONSIN - LA CROSSE
Entity type:Organization
Organization Name:UNIVERSITY OF WISCONSIN - LA CROSSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:608-785-8073
Mailing Address - Street 1:1725 STATE ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3742
Mailing Address - Country:US
Mailing Address - Phone:608-785-8073
Mailing Address - Fax:
Practice Address - Street 1:1725 STATE ST
Practice Address - Street 2:2106 CENTENNIAL HALL
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5460
Practice Address - Country:US
Practice Address - Phone:608-785-8073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF WISCONSIN - LA CROSSE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)