Provider Demographics
NPI:1023261211
Name:THE FAMILY RESOURCE GROUP
Entity type:Organization
Organization Name:THE FAMILY RESOURCE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:VANDERMAUSE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:608-575-7518
Mailing Address - Street 1:313 PRICE PL STE 11
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3250
Mailing Address - Country:US
Mailing Address - Phone:608-575-7518
Mailing Address - Fax:
Practice Address - Street 1:313 PRICE PL STE 11
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3250
Practice Address - Country:US
Practice Address - Phone:608-575-7518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2249261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42219100Medicaid