Provider Demographics
NPI:1487790044
Name:HUMAN DEVELOPMENT ASSOCIATES OF LACROSSE LLC
Entity type:Organization
Organization Name:HUMAN DEVELOPMENT ASSOCIATES OF LACROSSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATION MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KREUZER
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:608-784-8688
Mailing Address - Street 1:2920 EAST AVE S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LACROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-8282
Mailing Address - Country:US
Mailing Address - Phone:608-784-8688
Mailing Address - Fax:608-784-8684
Practice Address - Street 1:2920 EAST AVE S
Practice Address - Street 2:SUITE 101
Practice Address - City:LACROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-8282
Practice Address - Country:US
Practice Address - Phone:608-784-8688
Practice Address - Fax:608-784-8684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1425261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42125000Medicaid
WI42125000Medicaid