Provider Demographics
NPI:1053586412
Name:RUSK COUNTY CSP
Entity type:Organization
Organization Name:RUSK COUNTY CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED CLINCAL SOC
Authorized Official - Phone:715-532-5940
Mailing Address - Street 1:219 W 2ND ST NORTH
Mailing Address - Street 2:
Mailing Address - City:LADYSMITH
Mailing Address - State:WI
Mailing Address - Zip Code:54848
Mailing Address - Country:US
Mailing Address - Phone:715-532-5940
Mailing Address - Fax:715-532-5947
Practice Address - Street 1:219 W 2ND ST NORTH
Practice Address - Street 2:
Practice Address - City:LADY SMITH
Practice Address - State:WI
Practice Address - Zip Code:54848
Practice Address - Country:US
Practice Address - Phone:715-532-5940
Practice Address - Fax:715-532-5947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43429800Medicaid