Provider Demographics
NPI:1053503946
Name:NORTHWEST WISCONSIN COMMUNITY SERVICES AGENCY INC.
Entity type:Organization
Organization Name:NORTHWEST WISCONSIN COMMUNITY SERVICES AGENCY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:WIC PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:MAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CLE
Authorized Official - Phone:715-394-2750
Mailing Address - Street 1:1805 N 14TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-8802
Mailing Address - Country:US
Mailing Address - Phone:715-394-2750
Mailing Address - Fax:715-394-4651
Practice Address - Street 1:1805 N 14TH ST STE 4
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-8802
Practice Address - Country:US
Practice Address - Phone:715-394-2750
Practice Address - Fax:715-394-4651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44012100Medicaid