Provider Demographics
NPI:1396936175
Name:ECUMENICAL HEALTH CENTER
Entity type:Organization
Organization Name:ECUMENICAL HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:HEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:EDS
Authorized Official - Phone:920-491-9800
Mailing Address - Street 1:1540 CAPITOL DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2235
Mailing Address - Country:US
Mailing Address - Phone:920-491-9800
Mailing Address - Fax:920-491-9800
Practice Address - Street 1:1540 CAPITOL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2235
Practice Address - Country:US
Practice Address - Phone:920-491-9800
Practice Address - Fax:920-491-9800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI970057103TC1900X, 261QM0801X
WI104124251S00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39081000Medicaid