Provider Demographics
NPI:1932625357
Name:REFRESH MIDWEST OPERATIONS, SC
Entity type:Organization
Organization Name:REFRESH MIDWEST OPERATIONS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:715-381-1980
Mailing Address - Street 1:2501 HANLEY RD STE 202
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8705
Mailing Address - Country:US
Mailing Address - Phone:715-381-1980
Mailing Address - Fax:715-381-1906
Practice Address - Street 1:2501 HANLEY RD STE 202
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8705
Practice Address - Country:US
Practice Address - Phone:715-381-1980
Practice Address - Fax:715-381-1906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-17
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1436-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1669822763Medicaid
WI171-004-3070Medicaid
WI1053463976Medicaid
WI1245667633Medicaid
WI1336248137Medicaid
WI1427000991Medicaid
WI1649514803Medicaid
WI1518208206Medicaid
WI1689947384Medicaid