Provider Demographics
NPI:1912173519
Name:MARRIAGE & FAMILY HEALTH SERVICE, LTD
Entity type:Organization
Organization Name:MARRIAGE & FAMILY HEALTH SERVICE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:715-832-0238
Mailing Address - Street 1:2925 MONDOVI RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6141
Mailing Address - Country:US
Mailing Address - Phone:715-832-0238
Mailing Address - Fax:715-832-0771
Practice Address - Street 1:1107 HEART ISLAND PKWY
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-3900
Practice Address - Country:US
Practice Address - Phone:715-832-0238
Practice Address - Fax:715-832-0771
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARRIAGE & FAMILY HEALTH SERVICES, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI223799OtherMHN/TRICARE INS. CO.
WI43171526Medicaid
WI43171526Medicaid