Basic Information
| Provider Information | |||||||||
| NPI: | 1366896839 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELLIN PSYCHIATRIC CENTER INC | ||||||||
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| OtherOrganizationName: | BELLIN PSYCHIATRIC CENTER MARINETTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22040 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 2820 ROOSEVELT RD | ||||||||
| Address2: | |||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541433834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204336073 | ||||||||
| FaxNumber: | 9204370533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2016 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | STROOBANTS | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9204457226 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1598728776 | 05 | WI | MEDICAID | 2759 | 01 | WI | WI DSL LICENSE | OTHER |