Provider Demographics
NPI:1871731737
Name:MARQUETTE CHEMICAL DEPENDENCY SERVICE
Entity type:Organization
Organization Name:MARQUETTE CHEMICAL DEPENDENCY SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR FOR MCDS
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-441-0204
Mailing Address - Street 1:N3829 STATE ROAD 22
Mailing Address - Street 2:PO BOX 57
Mailing Address - City:MONTELLO
Mailing Address - State:WI
Mailing Address - Zip Code:53949-9049
Mailing Address - Country:US
Mailing Address - Phone:608-297-2085
Mailing Address - Fax:608-297-2426
Practice Address - Street 1:N3829 STATE ROAD 22
Practice Address - Street 2:
Practice Address - City:MONTELLO
Practice Address - State:WI
Practice Address - Zip Code:53949-9049
Practice Address - Country:US
Practice Address - Phone:608-297-2085
Practice Address - Fax:608-297-2426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1560251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management