Provider Demographics
NPI:1841466208
Name:OPERATION FRESH START
Entity type:Organization
Organization Name:OPERATION FRESH START
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:608-244-4721
Mailing Address - Street 1:1925 WINNEBAGO ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5314
Mailing Address - Country:US
Mailing Address - Phone:608-244-4721
Mailing Address - Fax:608-244-8162
Practice Address - Street 1:1925 WINNEBAGO ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5314
Practice Address - Country:US
Practice Address - Phone:608-244-4721
Practice Address - Fax:608-244-8162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70968030251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41868000OtherMEDICARE PROVIDER CERTIFICATION