Provider Demographics
NPI:1366538712
Name:VAN ROSSUM, NEIL C (MS, LCSW, CSAC)
Entity type:Individual
Prefix:
First Name:NEIL
Middle Name:C
Last Name:VAN ROSSUM
Suffix:
Gender:M
Credentials:MS, LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MENOMINEE COUNTY HUMAN SERVICES
Mailing Address - Street 2:P.O. BOX 280
Mailing Address - City:KESHENA
Mailing Address - State:WI
Mailing Address - Zip Code:54135-0280
Mailing Address - Country:US
Mailing Address - Phone:715-799-3861
Mailing Address - Fax:715-799-3517
Practice Address - Street 1:W3272 WOLF RIVER DRIVE
Practice Address - Street 2:
Practice Address - City:KESHENA
Practice Address - State:WI
Practice Address - Zip Code:54135-9202
Practice Address - Country:US
Practice Address - Phone:715-799-3861
Practice Address - Fax:715-799-3517
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI396123101Y00000X
WI1080-132101YA0400X
WI396-123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39220600Medicaid