| Organization Name: | STATE OF WISCONSIN |
| NPI Number: | 1164516506 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ROBERT G KNEEPKENS (DIRECTOR) |
| Mailing Address: | 1300 South Drive Winnebago |
| State: | WI US |
| Postal Code: | 549850009 |
| Phone Number: | 9202354910 |
| Fax Number: | 9202372043 |
| NPI Enumeration Date: | 10/02/2006 |
| NPI Last Update Date: | 02/15/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 283Q00000X |
| License Number: | 250 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Hospitals |
| Taxonomy Classification: | Psychiatric Hospital |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An organization including a physical plant and personnel that provides multidisciplinary diagnostic and treatment mental health services to patients requiring the safety, security, and shelter of the inpatient or partial hospitalization settings. |