Provider Demographics
NPI:1588703078
Name:STATE OF WISCONSIN
Entity type:Organization
Organization Name:STATE OF WISCONSIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CENTER DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-301-9229
Mailing Address - Street 1:317 KNUTSON DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-1133
Mailing Address - Country:US
Mailing Address - Phone:608-301-1946
Mailing Address - Fax:608-301-1871
Practice Address - Street 1:317 KNUTSON DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-1133
Practice Address - Country:US
Practice Address - Phone:608-301-1946
Practice Address - Fax:608-301-1871
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF WISCONSIN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-05
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1000-042320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5106770OtherNCPDP