Provider Demographics
NPI:1023167954
Name:RED CLIFF BAND OF CHIPPEWA INDIANS
Entity type:Organization
Organization Name:RED CLIFF BAND OF CHIPPEWA INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:CADC III
Authorized Official - Phone:715-779-3741
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54814-0529
Mailing Address - Country:US
Mailing Address - Phone:715-779-3741
Mailing Address - Fax:715-779-3765
Practice Address - Street 1:37390 N BRADUM RD
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814-4832
Practice Address - Country:US
Practice Address - Phone:715-779-3741
Practice Address - Fax:715-779-3765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty