Provider Demographics
NPI:1386713352
Name:COUNTY OF BROWN
Entity type:Organization
Organization Name:COUNTY OF BROWN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPPORT SERVICES COOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNOG
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LCSW, CADCIII
Authorized Official - Phone:920-391-6959
Mailing Address - Street 1:3150 GERSHWIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5859
Mailing Address - Country:US
Mailing Address - Phone:920-391-4839
Mailing Address - Fax:920-391-4870
Practice Address - Street 1:3150 GERSHWIN DRIVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5859
Practice Address - Country:US
Practice Address - Phone:920-391-4839
Practice Address - Fax:920-391-4870
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF BROWN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-06
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2615251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41761800Medicaid