Provider Demographics
NPI:1295974285
Name:DOOR COUNTY DEPT OF COMMUNITY PROGRAMS
Entity type:Organization
Organization Name:DOOR COUNTY DEPT OF COMMUNITY PROGRAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:KREBSBACH
Authorized Official - Suffix:
Authorized Official - Credentials:ICS, CSAC
Authorized Official - Phone:920-746-2345
Mailing Address - Street 1:421 NEBRASKA STREET
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-2249
Mailing Address - Country:US
Mailing Address - Phone:920-746-2345
Mailing Address - Fax:920-746-2439
Practice Address - Street 1:421 NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-2225
Practice Address - Country:US
Practice Address - Phone:920-746-2345
Practice Address - Fax:920-746-2439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1283251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32976600Medicaid