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Organization
NORTHEAST WISCONSIN BEHAVIORAL HEALTH SC
Active
Organization
NORTHEAST WISCONSIN BEHAVIORAL HEALTH SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SUZETTE MARIE KOSNAR-TITTL LICSW (OWNER, CEO, PROVIDER)
(920) 884-2175
Entity
Organization
Contact information
Practice address
529 SOUTH JEFFERSON STREET, SUITE 202, GREEN BAY, WI 54301-4125
(920) 884-2175
(920) 884-6735
Mailing address
529 SOUTH JEFFERSON STREET, SUITE 202, GREEN BAY, WI 54301-4125
(920) 884-2175
(920) 884-6735
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
4044-123
WI
101YM0800X
Mental Health Counselor
Primary
—
—
101YP2500X
Professional Counselor
2376 125
WI
1041C0700X
Clinical Social Worker
4044 123
WI
106H00000X
Marriage & Family Therapist
489 124
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000044900
CLINICMEDICARE# GREENBAY
WI
01
—
000044905
CLINICMEDICARE#OSHKOSH
WI
01
—
000144900
PROVIDERMEDICARE#GREENBAY
WI
01
—
000144905
PROVIDERMEDICARE#OSHKOSH
WI
01
—
1275733602
CLINIC NPI#
WI
01
—
1285736249
PROVIDER NPI
—
01
—
39722900
PROVIDER MEDICAID #
WI
01
—
4225100
CLINIC MEDICAID #
WI
Enumeration date
07/24/2007
Last updated
10/16/2023
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