Mental Health and Substance Abuse Programs in alphabetical
Mental Health and Substance Abuse Programs in alphabetical
Mental Health and Substance Abuse Programs in alphabetical
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DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 1 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1011<br />
16TH STREET BEHAVIORAL HEALTH CENTER<br />
PAUL WEST<br />
1032 S. 16TH STREET<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
paul.west@sschc.org<br />
Phone: (414) 672-3145<br />
Fax: (414) 383-5597<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/15/1997<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2682<br />
2ND CENTURY<br />
KATHY MURAWSKI<br />
2187 S 85TH STREET<br />
MILWAUKEE, WI 53227<br />
County: Milwaukee<br />
Kathy@arobhc.com<br />
Phone: (414) 321-5936<br />
Fax: (414) 321-5935<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
PARKWAY CLINIC Tier 1<br />
2906 S 20TH STREET<br />
11/01/2011<br />
MILWAUKEE, WI 53215<br />
10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/30/2006<br />
02/01/2011<br />
01/31/2012<br />
CSAS-Transitional Residential DHS 75.14<br />
1001<br />
A HEALING CENTER/EFFICIENCY MANAGEMENT<br />
CONSULTING, S.C.<br />
KAREN CRNKOVICH<br />
20860 WATERTOWN ROAD<br />
WAUKESHA, WI 53186<br />
County: Waukesha<br />
No Email Address Provided<br />
Phone: (262) 821-6117<br />
Fax: (262) 821-6119<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1987<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 2 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1083<br />
AALTO ENHANCEMENT CENTER, SC<br />
KATHRYN A. AALTO<br />
8503 - 75TH STREET, #A<br />
KENOSHA, WI 53142<br />
County: Kenosha<br />
aecalto@tds.net<br />
Phone: (262) 496-3586<br />
Fax: (262) 654-9379<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/09/1991<br />
07/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1004<br />
ABR COUNSELING SERVICES<br />
KATHY RUDD<br />
12 W. MARSHALL STREET, #100<br />
RICE LAKE, WI 54868<br />
County: Barron<br />
abrudd@chibardun.net<br />
Phone: (715) 234-3301<br />
Fax: (715) 736-1301<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1986<br />
10/01/2008<br />
09/30/2010<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1006<br />
ACACIA MENTAL HEALTH CLINIC, LLC<br />
ABE FREUND<br />
6040 W LISBON AVENUE, #102<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
afreund@amhcl<strong>in</strong>ic.com<br />
Phone: (414) 871-9111<br />
Fax: (414) 871-9121<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1992<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
10/01/2008 09/30/2010<br />
10/01/2008 09/30/2010<br />
ACACIA MENTAL HEALTH CLINIC, LLC Tier 1<br />
2931 S KINNICKINNIC AVENUE<br />
08/01/2012<br />
MILWAUKEE, WI 53207<br />
07/31/2014<br />
ACACIA MENTAL HEALTH CLINIC, LLC Tier 1<br />
1840 N FARWELL, #306D<br />
08/01/2012<br />
MILWAUKEE, WI 53210<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 3 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2027<br />
ACCESS MENTAL HEALTH CLINIC<br />
VICTOR LIKHTEREV<br />
1442 N. FARWELL AVE., #104<br />
MILWAUKEE, WI 53202<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 276-3455<br />
Fax: (414) 276-3460<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1998<br />
08/01/2010<br />
07/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2948<br />
ACCESS, INC COMMUNITY SUPPORT PROGRAM<br />
ANDY WOLF<br />
804 W 9TH STREET, N, #B<br />
LADYSMITH, WI 54848<br />
County: Rusk<br />
awolf@auroraservices.com<br />
Phone: (715) 532-9771<br />
Fax: (715) 532-9774<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/06/2011<br />
09/06/2011<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2633<br />
ACCESS, INC. COMMUNITY SUPPORT PROGRAM<br />
ANDREW WOLF<br />
24670 SOUTH RD, HWY 35/70, #1200<br />
SIREN, WI 54872<br />
County: Burnett<br />
No Email Address Provided<br />
Phone: (715) 349-7233<br />
Fax: (715) 349-7205<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2010 07/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2006<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
09/06/2011 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2011 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 4 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1007<br />
ACCESS, INC.<br />
ANDY WOLF<br />
408 RED CEDAR STREET, #1<br />
MENOMONIE, WI 54751<br />
County: Dunn<br />
awolf@auroraservices.com<br />
Phone: (715) 235-1839<br />
Fax: (715) 235-2688<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/01/1996<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2631<br />
ACCESS, INC.<br />
ANDREW WOLF<br />
4851 HWY 63 SOUTH<br />
SPOONER, WI 54801<br />
County: Washburn<br />
awolf@auroraservices.com<br />
Phone: (715) 635-4858<br />
Fax: (715) 635-4861<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
ACCESS, INC Tier 1<br />
1302 ARLEN COURT<br />
08/01/2012<br />
EAU CLAIRE, WI 54703<br />
07/31/2014<br />
ACCESS, INC. Tier 1<br />
102 W NORTH SHORE DRIVE<br />
08/01/2012<br />
NEW RICHMOND, WI 54017<br />
07/31/2014<br />
ACCESS, INC. Tier 1<br />
915 INDIANHEAD DRIVE<br />
08/01/2012<br />
MOSINEE, WI 54455<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2006<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2632<br />
ACCESS, INC.<br />
ANDREW WOLF<br />
24670 STATE ROAD 35/70, #1200<br />
SIREN, WI 54872<br />
County: Burnett<br />
awolf@auroraservices.com<br />
Phone: (715) 349-7233<br />
Fax: (715) 349-7205<br />
Surveyor: Bradley Jahr<br />
Services<br />
08/01/2012 07/31/2014<br />
ACCESS INC SPOONER-MIDDLE/HIGH<br />
SCHOOL<br />
Tier 1<br />
500 COLLEGE STREET<br />
01/01/2012<br />
SPOONER, WI 54801<br />
12/31/2013<br />
ACCESS, INC Tier 1<br />
330 E LASALLE STREET<br />
01/01/2012<br />
BARRON, WI 54812<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2006<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
ACCESS, INC Tier 1<br />
100 POLK COUNTY PLAZA, #70<br />
01/01/2012<br />
BALSAM LAKE, WI 54810<br />
12/31/2013<br />
ACCESS, INC. Tier 1<br />
480 E JAMES AVENUE<br />
01/01/2012<br />
GRANTSBURG, WI 54840<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 5 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2653<br />
ACCESS, INC<br />
ANDY WOLF<br />
804 W 9TH STREET N, # B<br />
LADYSMITH, WI 54848<br />
County: Rusk<br />
awolf@auroraservices.com<br />
Phone: (715) 532-9771<br />
Fax: (715) 532-9774<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/2006<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2719<br />
ACHIEVE CENTER<br />
CAROL WESLEY<br />
2600 STEWART AVENUE, #38<br />
WAUSAU, WI 54401<br />
County: Marathon<br />
cwesley@uachievecenter.com<br />
Phone: (715) 845-4900<br />
Fax: (715) 845-4970<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
ACCESS INC/RUSK COUNTY JAIL Tier 1<br />
311 E MINER AVENUE<br />
08/01/2012<br />
LADYSMITH, WI 54848<br />
07/31/2014<br />
ACCESS, INC Tier 1<br />
115 E 6TH STREET SOUTH<br />
08/01/2012<br />
LADYSMITH, WI 54848<br />
07/31/2014<br />
ACCESS, INC SCHOOL DISTRICT OF<br />
FLAMBEAU<br />
Tier 1<br />
N 4540 CTY HWY I<br />
08/01/2012<br />
TONY, WI 54563<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2007<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1009<br />
ACHIEVEMENT ASSOCIATES, LTD.<br />
NEENA FLORSHEIM<br />
1317 W. TOWNE SQUARE ROAD<br />
MEQUON, WI 53092<br />
County: Ozaukee<br />
AALTEAM@aol.com<br />
Phone: (262) 241-5099<br />
Fax: (262) 241-5054<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1998<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2011 05/31/2013<br />
06/01/2011 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 6 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1010<br />
ACHIEVEMENT ASSOCIATES, LTD.<br />
NEENA FLORSHEIM<br />
11040 WEST BLUEMOUND RD<br />
MILWAUKEE, WI 53226<br />
County: Milwaukee<br />
AALTEAM@aol.com<br />
Phone: (262) 241-5099<br />
Fax: (262) 241-5054<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1993<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2735<br />
ACS CLINICAL SERVICES LLC<br />
TIFFANY WALKER<br />
303 W COURT STREET, LOWER LEVEL<br />
JANESVILLE, WI 53548<br />
County: Rock<br />
janesville@correctionalservices.org<br />
Phone: (608) 743-1736<br />
Fax: (608) 743-1759<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
ACHIEVEMENT ASSOCIATES LTD Tier 1<br />
1110 NORTH OLD WORLD 3RD STREET #410 06/01/2011<br />
MILWAUKEE, WI 53201<br />
05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/13/2007<br />
04/01/2012<br />
03/31/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2873<br />
ACS CLINICAL SERVICES, LLC - STEVENS POINT<br />
MARK ROSSANO<br />
3440 B CHURCH STREET<br />
STEVENS POINT, WI 54481<br />
County: Portage<br />
stpo<strong>in</strong>tcl<strong>in</strong>ic@acscl<strong>in</strong>icalservices.org<br />
Phone: (715) 295-9618<br />
Fax: (715) 295-9621<br />
Surveyor: Bradley Jahr<br />
Services<br />
06/01/2011 05/31/2013<br />
06/01/2011 05/31/2013<br />
ACS CLINICAL SERVICES - BEAVER DAM Tier 1<br />
1212 DECLARK STREET<br />
07/25/2012<br />
BEAVER DAM, WI 53916<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/15/2009<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
ACS CLINICAL SERVICES,<br />
LLC-MARATHON<br />
1699 SCHOFIELD AVENUE, # 116<br />
SCHOFIELD, WI 54476<br />
04/01/2012 03/31/2014<br />
Tier 1<br />
06/16/2011<br />
09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 7 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2608<br />
ACS CLINICAL SERVICES<br />
REBECCA GREEN<br />
720 W WASHINGTON STREET<br />
APPLETON, WI 54912<br />
County: Outagamie<br />
rgreen@correctionalservices.org<br />
Phone: (920) 830-1750<br />
Fax: (920) 830-1770<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/2005<br />
09/01/2012<br />
08/31/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2810<br />
ADAMS COUNTY HEALTH & HUMAN SERVICES<br />
DEPT COMPREHENSIVE COMMUNITY SERVICES<br />
PHILLIP W ROBINSON<br />
108 E NORTH STREET<br />
FRIENDSHIP, WI 53934<br />
County: Adams<br />
prob<strong>in</strong>son@co.adams.wi.us<br />
Phone: (608) 339-4505<br />
Fax: (608) 339-4593<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
ACS CLINICAL SERVICES - MANITOWOC Tier 2<br />
33 E WALDO BLVD<br />
09/01/2012<br />
MANITOWOC, WI 54220<br />
08/31/2014<br />
ACS CLINICAL SERVICES - SHEBOYGAN Tier 2<br />
1512 SOUTH 12TH ST<br />
09/01/2012<br />
SHEBOYGAN, WI 53081<br />
08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/10/2008<br />
03/01/2012<br />
02/28/2014<br />
Comprehensive Community Services (CCS) DHS 36<br />
1253<br />
ADAMS COUNTY HEALTH AND HUMAN SERVICES<br />
DEPARTMENT<br />
PHILIP ROBINSON<br />
108 E. NORTH STREET<br />
FRIENDSHIP, WI 53934<br />
County: Adams<br />
prob<strong>in</strong>son@co.adams.wi.us<br />
Phone: (608) 339-4505<br />
Fax: (608) 339-4585<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2012 08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1990<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 8 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2258<br />
ADDICTION RESOURCE COUNCIL, INC.<br />
CLAUDIA ROSKA<br />
741 N GRAND AVE, SUITE 300<br />
WAUKESHA, WI 53186<br />
County: Waukesha<br />
croska@arcouncil.net<br />
Phone: (262) 524-7921<br />
Fax: (262) 524-7932<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/26/2000<br />
07/01/2011<br />
06/30/2013<br />
CSAS-Intervention DHS 75.16<br />
CSAS-Prevention DHS 75.04<br />
2844<br />
ADKINS COUNSELING SERVICES<br />
MARCELLA ADKINS<br />
6001 W CENTER STREET, #208<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
adk<strong>in</strong>scounsel<strong>in</strong>g@yahoo.com<br />
Phone: (414) 393-1099<br />
Fax: (414) 393-9773<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/22/2009<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2568<br />
ADRIANNA HOUSE<br />
LARRY BUTLER<br />
2528 W HIGHLAND BOULEVARD<br />
MILWAUKEE, WI 53233<br />
County: Milwaukee<br />
ahbill<strong>in</strong>g@wi.rr.com<br />
Phone: (414) 933-7323<br />
Fax: (414) 933-7354<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/16/2004<br />
01/01/2009<br />
12/31/2009<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2009 12/31/2009
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 9 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1017<br />
AFFILIATED CLINICAL SERVICES, INC.<br />
DEBRA PIETSCH<br />
400 W. RIVER DRIVE<br />
WEST BEND, WI 53090<br />
County: Wash<strong>in</strong>gton<br />
acs2001@affiliatedcl<strong>in</strong>ical.com<br />
Phone: (262) 338-2717<br />
Fax: (262) 338-9767<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1984<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2851<br />
AFFILIATED CLINICAL SERVICES, INC.<br />
DEBRA PIETSCH<br />
1784 BARTON AVENUE, #13<br />
WEST BEND, WI 53090<br />
County: Wash<strong>in</strong>gton<br />
acs2001@affiliatedcl<strong>in</strong>ical.com<br />
Phone: (262) 338-2717<br />
Fax: (262) 338-9767<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
AFFILIATED CLINICAL SERVICES INC Tier 2<br />
38 SELL DRIVE #B<br />
07/01/2012<br />
HARTFORD, WI 53027<br />
06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2009<br />
03/01/2012<br />
02/28/2014<br />
CSAS-Day Treatment DHS 75.12<br />
1018<br />
AFFILIATED COUNSELING CENTER, LLC<br />
SANDRA SCHWEFEL-MASSIE<br />
108 N LINCOLN AVENUE<br />
BEAVER DAM, WI 53916<br />
County: Dodge<br />
exdir@affiliatedcounsel<strong>in</strong>g.net<br />
Phone: (920) 887-8751<br />
Fax: (920) 887-3977<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1989<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
03/01/2012 02/28/2014<br />
AFFILIATED COUNSELING CENTER, LLC Tier 1<br />
17 FOREST AVENUE<br />
10/01/2011<br />
FOND DU LAC, WI 54935<br />
09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 10 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2650<br />
AFFILIATED WELLNESS GROUP, LLC<br />
JENNIFER JONES<br />
2301 SUN VALLEY DRIVE, #209<br />
DELAFIELD, WI 53018<br />
County: Waukesha<br />
Bethechange8@hotmail.com<br />
Phone: (262) 646-8288<br />
Fax: (262) 646-8255<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/27/2006<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1020<br />
AFFINITY HOUSE<br />
ANITA KUSTER<br />
3042 KILBOURNE AVENUE<br />
EAU CLAIRE, WI 54703<br />
County: Eau Claire<br />
akuster00@lsswis.org<br />
Phone: (715) 833-0436<br />
Fax: (715) 833-1505<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1992<br />
03/01/2012<br />
02/28/2014<br />
CSAS-Transitional Residential DHS 75.14<br />
2651<br />
AFFINITY MEDICAL GROUP - BEHAVIORAL<br />
HEALTH<br />
TINA LECHNIR<br />
1531 S MADISON ST, #580<br />
APPLETON, WI 54915<br />
County: Outagamie<br />
tlechnirb @aff<strong>in</strong>ityhealth.org<br />
Phone: (920) 730-4411<br />
Fax: (920) 730-5481<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/20/2005<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
03/01/2012 02/28/2014<br />
AFFINITY MEDICAL GROUP-BEHAVIORAL<br />
HEALTH<br />
Tier 1<br />
2601 FIELDCREST<br />
11/01/2011<br />
KAUKAUNA, WI 54130<br />
10/31/2013<br />
AFFINITY MEDICAL GROUP-BEHAVIORAL<br />
HEALTH<br />
Tier 1<br />
200 PATRIOT DRIVE<br />
11/01/2011<br />
LITTLE CHUTE, WI 54140<br />
10/31/2013<br />
AFFINITY MEDICAL GROUP-BEHAVIORAL<br />
HEALTH<br />
Tier 1<br />
1855 S KOELLER<br />
11/01/2011<br />
OSHKOSH, WI 54902<br />
10/31/2013<br />
CALUMET MEDICAL CENTER CLINIC Tier 1<br />
618 MEMORIAL DRIVE<br />
11/01/2011<br />
CHILTON, WI 53014<br />
10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 11 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1022<br />
AGAPE RECOVERY CENTER<br />
PATRICIA A GRAMKE<br />
201 N PINE<br />
BURLINGTON, WI 53105<br />
County: Rac<strong>in</strong>e<br />
agape1995@att.net<br />
Phone: (262) 767-0441<br />
Fax: (262) 767-9072<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/1994<br />
04/01/2011<br />
03/31/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2226<br />
AGNESIAN HEALTHCARE DBA DOLL AND<br />
ASSOCIATES<br />
BETH ROGERS-DOLL<br />
40 CAMELOT DRIVE<br />
FOND DU LAC, WI 54935<br />
County: Fond Du Lac<br />
brdoll@doll<strong>and</strong>associates.com<br />
Phone: (920) 907-8206<br />
Fax: (920) 907-8209<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/05/2000<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1753<br />
AGNESIAN HEALTHCARE, D.B.A. PSYCHIATRIC<br />
ASSOCIATES<br />
JIM SALASEK<br />
200 FRONT STREET, #3D<br />
BEAVER DAM, WI 53916<br />
County: Dodge<br />
salasekj@agnesian.com<br />
Phone: (920) 885-2780<br />
Fax: (920) 885-2788<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1984<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 12 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2406<br />
AIDS RESOURCE CENTER OF WISCONSIN<br />
KEVIN ROEDER<br />
820 N. PLANKINTON AVENUE<br />
MILWAUKEE, WI 53203<br />
County: Milwaukee<br />
Kev<strong>in</strong>.Roeder@arcw.org<br />
Phone: (414) 225-1540<br />
Fax: (414) 225-1628<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/02/2002<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1205<br />
AJA ENTERPRISE, LLC - AJA COUNSELING CTR &<br />
CHILD & ADOLESCENT DAY TREATMENT<br />
BEVELYN JOHNSON<br />
8726 WEST MILL ROAD<br />
MILWAUKEE, WI 53225<br />
County: Milwaukee<br />
bevjohnson2003@yahoo.com<br />
Phone: (414) 353-9250<br />
Fax: (414) 353-2095<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
AIDS RESOURCE CENTER OF WI-GREEN<br />
BAY<br />
Tier 2<br />
445 S ADAMS STREET<br />
01/01/2011<br />
GREEN BAY, WI 54301<br />
12/31/2012<br />
AIDS RESOURCE CENTER OF<br />
WI-KENOSHA<br />
Tier 1<br />
1212 - 57TH STREET<br />
01/01/2011<br />
KENOSHA, WI 53140<br />
12/31/2012<br />
AIDS RESOURCE CENTER OF<br />
WI-WAUSAU<br />
Tier 1<br />
1105 GRAND AVENUE, #1<br />
01/01/2011<br />
WAUSAU, WI 54403<br />
12/31/2012<br />
AIDS RESOURCE CTR OF WI-APPLETON Tier 1<br />
103 E WASHINGTON STREET, #1002 01/01/2011<br />
APPLETON, WI 54911<br />
12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/16/1996<br />
03/01/2012<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
03/01/2011 12/31/2012<br />
03/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2012 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 13 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1023<br />
ALCOCARE, INC NEW DAWN RESIDENTIAL<br />
TREATMENT<br />
THOMAS BOLAN<br />
786 S MAIN STREET<br />
JANESVILLE, WI 53548<br />
County: Rock<br />
alcocare@att.net<br />
Phone: (608) 754-6800<br />
Fax: (608) 754-2651<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/16/1994<br />
05/01/2011<br />
04/30/2013<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
2512<br />
ALL-AREA COUNSELING SERVICES-A DIVISION OF<br />
OPTIONS TREATMENT PROGRAMS, INC<br />
KIMEKO HAGEN<br />
719 W MAIN STREET<br />
WAUTOMA, WI 54982<br />
County: Waushara<br />
khagen@optionstx.com<br />
Phone: (920) 787-7472<br />
Fax: (920) 787-5458<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2004<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2134<br />
ALLIANCE COUNSELING CENTER<br />
GERALD FLANAGAN<br />
300 COTTONWOOD AVENUE, #4<br />
HARTLAND, WI 53029<br />
County: Waukesha<br />
alliance-jf@sbcglobal.net<br />
Phone: (262) 896-0905<br />
Fax: (262) 781-6603<br />
Surveyor: Mark Isaacs<br />
Services<br />
OPTIONS TREATMENT<br />
PROGRAMS-OSHKOSH<br />
502 E. NEW YORK AVE.<br />
OSHKOSH, WI 54901<br />
05/01/2011 04/30/2013<br />
Tier 2<br />
08/01/2012<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/06/1999<br />
02/01/2012<br />
01/31/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
ALLIANCE COUNSELING CENTER Tier 1<br />
2312 N GRANDVIEW BOULEVARD, #103 02/01/2012<br />
WAUKESHA, WI 53188<br />
01/31/2013<br />
ALLIANCE COUNSELING CENTER Tier 1<br />
N91 W17194 APPLETON AVE, #105<br />
02/01/2012<br />
MENOMONEE FALLS, WI 53051<br />
01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 14 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2975<br />
ALLIANCE INDIVIDUAL & FAMILY SERVICES LLC<br />
ALFREDA MITCHELL<br />
9310 NORTH 107TH STREET<br />
MILWAUKEE, WI 53224<br />
County: Milwaukee<br />
adm<strong>in</strong>istration@allianceIFS.com<br />
Phone: (414) 355-5594<br />
Fax: (414) 751-5166<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/01/2012<br />
08/01/2012<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1033<br />
ALTERNATIVES IN PSYCHOLOGICAL<br />
CONSULTATION, S.C.<br />
KAREN DREXLER<br />
10045 W LISBON AVENUE, #221<br />
WAUWATOSA, WI 53222<br />
County: Milwaukee<br />
kdrexler@altlig.com<br />
Phone: (414) 358-7144<br />
Fax: (414) 358-7158<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/20/1997<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2368<br />
AMERICAN BEHAVIORAL CLINICS<br />
JAY SCHRINSKY<br />
1240 W. RANCHITO LANE<br />
MEQUON, WI 53092<br />
County: Ozaukee<br />
jhschr<strong>in</strong>sky@gmail.com<br />
Phone: (262) 241-3231<br />
Fax: (262) 241-4311<br />
Surveyor: Mark Isaacs<br />
Services<br />
08/01/2012 07/31/2013<br />
ALTERNATIVES IN PSYCH CONSULT Tier 1<br />
5757 WEST OKLAHOMA AVE<br />
12/01/2011<br />
WEST ALLIS, WI 53219<br />
11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2002<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
AMERICAN BEHAVIORAL<br />
CLINICS-BLUEMOUND #1<br />
10424 W BLUEMOUND ROAD<br />
MILWAUKEE, WI 53226<br />
AMERICAN BEHAVIORAL<br />
CLINICS-BLUEMOUND #2<br />
9720 W BLUEMOUND ROAD<br />
MILWAUKEE, WI 53226<br />
AMERICAN BEHAVIORAL CLINICS-ELM<br />
GROVE<br />
15285 WATERTOWN PLANK ROAD<br />
ELM GROVE, WI 53122<br />
AMERICAN BEHAVIORAL<br />
CLINICS-LAYTON<br />
7330 W LAYTON AVENUE<br />
MILWAUKEE, WI 53220<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
Tier 2<br />
06/01/2012<br />
05/31/2014<br />
Tier 1<br />
06/01/2012<br />
05/31/2014<br />
Tier 2<br />
06/01/2012<br />
05/31/2014<br />
Tier 2<br />
06/01/2012<br />
05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2014<br />
06/01/2012 05/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 15 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1035<br />
AMERICAN FOUNDATION OF COUNSELING<br />
SERVICES, INC.<br />
MICHAEL HOGAN<br />
130 E. WALNUT STREET, #706<br />
GREEN BAY, WI 54301<br />
County: Brown<br />
mhogan@afcscounsel<strong>in</strong>g.org<br />
Phone: (920) 437-8256<br />
Fax: (920) 437-1188<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/1981<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2839<br />
AMERY REGIONAL MEDICAL CENTER<br />
BEHAVIORAL HEALTH CENTER<br />
COLLEEN ERB<br />
230 DERONDA STREET<br />
AMERY, WI 54001<br />
County: Polk<br />
colleene@amerymedial.com<br />
Phone: (715) 268-0070<br />
Fax: (715) 268-0071<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/08/2008<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2875<br />
AMRI COUNSELING SERVICES, LLC<br />
LAKEIA JONES<br />
1915 N MARTIN LUTHER KING JR DR #213D<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
amricounsel<strong>in</strong>g@yahoo.com<br />
Phone: (414) 759-6377<br />
Fax: (866) 719-3024<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2009<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 16 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1037<br />
AMY SCHLEY, PH.D., S.C.<br />
DANN SMITH<br />
204 WISCONSIN AVENUE<br />
WAUKESHA, WI 53186<br />
County: Waukesha<br />
schleyteam@sbcglobal.net<br />
Phone: (262) 542-6694<br />
Fax: (262) 542-6213<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1992<br />
09/01/2008<br />
08/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2529<br />
ANDERSON & ASSOCIATES COUNSELING AND<br />
PSYCHOLOGIST SERVICES<br />
ERIC ANDERSON<br />
712 E 2ND STREET<br />
MERRILL, WI 54452<br />
County: L<strong>in</strong>coln<br />
psydoceric@gmail.com<br />
Phone: (715) 539-8080<br />
Fax: (715) 539-8099<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2004<br />
01/01/2012<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2874<br />
ANGELS COUNSELING & THERAPY SERVICE<br />
AUGUSTINA GARBA<br />
1401 N MARTIN LUTHER KING DRIVE<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
angelscounsel<strong>in</strong>g@gmail.com<br />
Phone: (414) 630-0102<br />
Fax: (414) 455-8362<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2008 08/31/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2009<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
01/01/2012 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2011 07/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 17 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2552<br />
ANXIETY, STRESS AND DEPRESSION CENTER<br />
GERALD METALSKY, PHD<br />
103 W. COLLEGE AVENUE, #1125<br />
APPLETON, WI 54911<br />
County: Outagamie<br />
metalsky@metalsky.com<br />
Phone: (920) 730-1088<br />
Fax: (920) 730-1096<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/2004<br />
11/01/2008<br />
10/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2734<br />
APPLIED THERAPIES AND WELLNESS CENTER SC<br />
TRISHA WOLLIN<br />
1033 N MAYFAIR ROAD, #305<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
twoll<strong>in</strong>@appliedtherapies<strong>and</strong>wellness.com<br />
Phone: (414) 302-1233<br />
Fax: (414) 302-1234<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/30/2007<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1050<br />
ARBOR PLACE, INC.<br />
JILL GAMEZ<br />
320 - 21ST STREET NE<br />
MENOMONIE, WI 54751<br />
County: Dunn<br />
<strong>in</strong>fo@arborplace<strong>in</strong>c.com<br />
Phone: (715) 235-4537<br />
Fax: (715) 235-4535<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2008 10/31/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1993<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
CSAS-Residential Intoxication Monitor<strong>in</strong>g DHS 75.09<br />
CSAS-Transitional Residential DHS 75.14<br />
06/01/2012 05/31/2014<br />
06/01/2012 05/31/2014<br />
ARBOR PLACE - BOYCEVILLE BRANCH Tier 1<br />
715 STATE HWY 79<br />
07/06/2012<br />
BOYCEVILLE, WI 54725<br />
09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 18 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1053<br />
ARC COMMUNITY SERVICES, INC. MADISON<br />
LAURA PARKER<br />
1409 EMIL STREET, #100<br />
MADISON, WI 53713<br />
County: Dane<br />
laurap@arccommserv.com<br />
Phone: (608) 283-6426<br />
Fax: (608) 283-6374<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1995<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1054<br />
ARC HOUSE<br />
CELESTA MILLER<br />
202 N. PATERSON STREET<br />
MADISON, WI 53703<br />
County: Dane<br />
cmiller@arccommserv.com<br />
Phone: (608) 283-6430<br />
Fax: (608) 283-6432<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
DAY REPORTING CENTER Tier 1<br />
7017 RAYWOOD ROAD<br />
06/07/2012<br />
MADISON, WI 53713<br />
02/28/2013<br />
SUMMIT CREDIT UNION COMMUNITY<br />
ROOM<br />
Tier 1<br />
1333 W MAIN STREET<br />
09/19/2011<br />
SUN PRAIRIE, WI 53590<br />
02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1990<br />
12/01/2011<br />
11/30/2013<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
1058<br />
ARO COUNSELING CENTERS, INC.<br />
DAWN ROLLING<br />
2314 N GRANDVIEW BOULEVARD, #301<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
dawn@arobhc.com<br />
Phone: (262) 524-9416<br />
Fax: (262) 524-9434<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/1992<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
12/01/2011 11/30/2013<br />
ARO COUNSELING CENTERS, INC Tier 2<br />
101 PIER STREET<br />
08/01/2012<br />
PORT WASHINGTON, WI 53074<br />
07/31/2014<br />
ARO COUNSELING CENTERS, INC Tier 2<br />
285 W JANACEK ROAD<br />
08/01/2012<br />
BROOKFIELD, WI 53045<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 19 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2174<br />
ARO COUNSELING CENTERS, INC.<br />
KATHY MURAWSKI<br />
6416 S. HOWELL AVENUE<br />
OAK CREEK, WI 53154<br />
County: Milwaukee<br />
Kathy@arobhc.com<br />
Phone: (414) 762-5429<br />
Fax: (414) 762-9727<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1999<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2239<br />
ASHA FAMILY SERVICES<br />
JOICE CAIN<br />
3719 W CENTER STREET<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
msjoiceca<strong>in</strong>@yahoo.com<br />
Phone: (414) 875-1511<br />
Fax: (414) 875-1217<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
ARO COUNSELING CENTERS INC Tier 2<br />
4325 S 60TH STREET, #3<br />
11/01/2011<br />
GREENFIELD, WI 53220<br />
10/31/2013<br />
ARO COUNSELING CENTERS INC Tier 2<br />
5408 W BURLEIGH ST<br />
11/01/2011<br />
MILWAUKEE, WI 53210<br />
10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/11/2000<br />
01/01/2011<br />
12/31/2012<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1064<br />
ASHLAND AREA COUNCIL ON AODA, INC.<br />
RANDALL P. SPANGLE<br />
502 W. MAIN, #305<br />
ASHLAND, WI 54806<br />
County: Ashl<strong>and</strong><br />
aaco@centurytel.net<br />
Phone: (715) 682-5207<br />
Fax: (715) 682-5209<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1984<br />
09/01/2012<br />
08/31/2014<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 20 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2639<br />
ASHLAND COUNTY HEALTH AND HUMAN<br />
SERVICES/NORTHLAND COUNSELING SERVICES<br />
TERRI PERRY<br />
1619 WEST THIRD STREET<br />
ASHLAND, WI 54806<br />
County: Ashl<strong>and</strong><br />
terri@hsd.co.ashl<strong>and</strong>.wi.us<br />
Phone: (715) 682-7004<br />
Fax: (715) 682-7924<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/26/2006<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 w/Telehealth DHS 34.3<br />
1066<br />
ASPEN FAMILY COUNSELING<br />
BARRY ERATH<br />
2639 NEW PINERY ROAD, #1<br />
PORTAGE, WI 53901<br />
County: Columbia<br />
berath@aspenfc.com<br />
Phone: (608) 742-5020<br />
Fax: (608) 742-3641<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1997<br />
01/01/2011<br />
12/31/2012<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2752<br />
ASPIRUS BEHAVIORAL MEDICINE CLINIC<br />
KRISTINE BELL<br />
520 N 28TH AVENUE, #200<br />
WAUSAU, WI 54401<br />
County: Marathon<br />
No Email Address Provided<br />
Phone: (715) 847-0094<br />
Fax: (705) 847-0092<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2007<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
01/01/2011 12/31/2012<br />
ASPIRUS BEHAVIORAL MEDICINE CLINIC Tier 2<br />
425 PINE RIDGE BLVD, #305B<br />
03/01/2012<br />
WAUSAU, WI 54401<br />
02/28/2014<br />
ASPIRUS BEHAVIORAL MEDICINE CLINIC<br />
WESTON<br />
4005 COMMUNITY CENTER DR<br />
WESTON, WI 54476<br />
Tier 2<br />
03/01/2012<br />
02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2012 02/28/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 21 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2294<br />
ASPIRUS WAUSAU HOSPITAL/BEHAVIORAL<br />
HEALTH SERVICES<br />
AEKTA DASSOW<br />
333 PINE RIDGE BOULEVARD<br />
WAUSAU, WI 54401<br />
County: Marathon<br />
No Email Address Provided<br />
Phone: (715) 847-2215<br />
Fax: (715) 847-2209<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/2001<br />
03/01/2011<br />
06/30/2011<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2060<br />
ASSOCIATED COUNSELING & RECOVERY<br />
CENTER, LLC<br />
JUDITH A. POLLARD<br />
551 W. JOHNSON STREET<br />
FOND DU LAC, WI 54935<br />
County: Fond Du Lac<br />
acrc2@sbcglobal.net<br />
Phone: (920) 907-0097<br />
Fax: (920) 907-0109<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/12/1998<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1069<br />
ASSOCIATED MENTAL HEALTH CONSULTANTS,<br />
INC.<br />
CURT AMMEL<br />
2600 N. MAYFAIR ROAD, #305<br />
MILWAUKEE, WI 53226<br />
County: Milwaukee<br />
amhc2600@sbcglobal.net<br />
Phone: (414) 257-0233<br />
Fax: (414) 257-3588<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 06/30/2011<br />
03/01/2011 06/30/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1982<br />
06/01/2009<br />
05/31/2011<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2009 05/31/2011
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 22 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1070<br />
ASSOCIATED PSYCHIATRIC & CONSULTING<br />
SERVICES<br />
TREVA LEUPOLD<br />
10425 W. NORTH AVENUE, #350<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 259-9516<br />
Fax: No Number Provided<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1978<br />
09/01/2009<br />
08/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1072<br />
ASSOCIATED THERAPIES<br />
JULAINE SIEWERT<br />
8989 N. PT. WASHINGTON RD #220<br />
MILWAUKEE, WI 53217<br />
County: Milwaukee<br />
msiewert1@wi.rr.com<br />
Phone: (414) 352-3336<br />
Fax: (414) 352-3928<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1992<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1075<br />
ASSOCIATES IN PSYCHOTHERAPY<br />
ELIZABETH MAGNUS<br />
1519 PRIMROSE LANE<br />
JANESVILLE, WI 53545<br />
County: Rock<br />
apcl<strong>in</strong>ic@choiceonemail.com<br />
Phone: (608) 752-7255<br />
Fax: (608) 752-6942<br />
Surveyor: William Rohner<br />
Services<br />
09/01/2009 08/31/2011<br />
ASSOCIATED THERAPIES Tier 1<br />
17160 W NORTH AVENUE<br />
04/01/2011<br />
BROOKFIELD, WI 53005<br />
03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/1980<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
04/01/2011 03/31/2013<br />
ASSOCIATES IN PSYCHOTHERAPY Tier 1<br />
636 PARK STREET<br />
06/01/2012<br />
BELOIT, WI 53511<br />
05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 23 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1076<br />
ATTIC CORRECTIONAL SERVICES, INC. ACS<br />
CLINICAL SERVICES<br />
TIFFANY WALKER<br />
1709 S. PARK STREET SUITE 1<br />
MADISON, WI 53713<br />
County: Dane<br />
madison@correctionalservices.org<br />
Phone: (608) 255-0307<br />
Fax: (608) 255-4005<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/25/2010<br />
04/01/2011<br />
03/31/2013<br />
CSAS-Intervention DHS 75.16<br />
2807<br />
ATTIC CORRECTIONAL SERVICES, INC-ACS<br />
CLINICAL SERVICES, LLC-SCHOFIELD<br />
MARK ROSSANO<br />
121 SKELLY STREET<br />
SCHOFIELD, WI 54476<br />
County: Marathon<br />
mrossano@acscl<strong>in</strong>icalservices.org<br />
Phone: (715) 355-0671<br />
Fax: (715) 355-0667<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2008<br />
10/01/2010<br />
09/30/2012<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1650<br />
AURORA BEHAVIORAL HEALTH - FRANKLIN<br />
KATHERINE CONNELLY<br />
9200 W. LOOMIS ROAD, #217<br />
FRANKLIN, WI 53132<br />
County: Milwaukee<br />
Kate.Connelly@aurora.org<br />
Phone: (414) 425-6506<br />
Fax: (414) 454-6450<br />
Surveyor: Demetrius Anderson<br />
Services<br />
ATTIC-ACS CLINICAL<br />
SERVICES-MERRILL<br />
1004 E 1ST STREET<br />
MERRILL, WI 54452<br />
04/01/2011 03/31/2013<br />
Tier 1<br />
09/13/2011<br />
09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/02/1994<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
10/01/2010 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 24 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1335<br />
AURORA BEHAVIORAL HEALTH - NORTH SHORE<br />
KATE CONNELLY<br />
6980 N. PORT WASHINGTON, #202<br />
MILWAUKEE, WI 53217<br />
County: Milwaukee<br />
kate.connelly@aurora.org<br />
Phone: (414) 454-6506<br />
Fax: (414) 454-6450<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/01/1985<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1386<br />
AURORA BEHAVIORAL HEALTH CENTER -<br />
MANITOWOC<br />
SOUMIT PENDHARKAR<br />
5300 MEMORIAL DRIVE<br />
TWO RIVERS, WI 54241<br />
County: Manitowoc<br />
No Email Address Provided<br />
Phone: (920) 793-7420<br />
Fax: (608) 793-7391<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
AURORA BEHAVIORAL HEALTH -<br />
HARTFORD<br />
1640 E SUMNER STREET<br />
WEST BEND, WI 53095<br />
AURORA BEHAVIORAL HEALTH - WEST<br />
BEND<br />
205 VALLEY AVENUE<br />
WEST BEND, WI 53095<br />
Tier 1<br />
08/01/2012<br />
07/31/2014<br />
Tier 2<br />
08/01/2012<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1993<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1839<br />
AURORA BEHAVIORAL HEALTH CENTER - SINAI<br />
KATE CONNELLY<br />
1020 N 12TH STREET, 4TH FLOOR<br />
MILWAUKEE, WI 53233<br />
County: Milwaukee<br />
kate.connelly@aurora.org<br />
Phone: (414) 219-5000<br />
Fax: (414) 219-5422<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1987<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 25 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2386<br />
AURORA BEHAVIORAL HEALTH CENTER -<br />
WAUKESHA<br />
KATE CONNELLY<br />
W231 N1440 HWY. CORPORATE CT #310<br />
WAUKESHA, WI 53186<br />
County: Waukesha<br />
kate.connelly@aurora.org<br />
Phone: (262) 896-6186<br />
Fax: (262) 896-6139<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/2002<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2518<br />
AURORA BEHAVIORAL HEALTH CENTER -<br />
WAUWATOSA<br />
KATE CONNELLY<br />
1220 DEWEY AVENUE<br />
WAUWATOSA, WI 53213<br />
County: Milwaukee<br />
Kate.Connelly@aurora.org<br />
Phone: (414) 454-6506<br />
Fax: (414) 454-6450<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
AURORA BEHAVIORAL HEALTH<br />
CENTER-WAUKESHA<br />
36500 AURORA DRIVE<br />
SUMMIT, WI 53066<br />
Tier 2<br />
05/01/2012<br />
04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/31/2004<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2397<br />
AURORA BEHAVIORAL HEALTH CENTER -<br />
WOMEN'S PAVILION<br />
KATE CONNELLY<br />
8901 W. LINCOLN AVENUE<br />
WEST ALLIS, WI 53227<br />
County: Milwaukee<br />
kate.connelly@aurora.org<br />
Phone: (414) 454-6506<br />
Fax: (414) 454-6450<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/12/2002<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 26 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2736<br />
AURORA BEHAVIORAL HEALTH CENTER<br />
SARA HEBEL<br />
1881 CHICAGO STREET<br />
DE PERE, WI 54115<br />
County: Brown<br />
sara.hebel@aurora.org<br />
Phone: (920) 403-8061<br />
Fax: (920) 403-8209<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/08/2007<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1336<br />
AURORA FAMILY SERVICE, INC.<br />
ROBERT MARRS<br />
3200 W. HIGHLAND BOULEVARD<br />
MILWAUKEE, WI 53208<br />
County: Milwaukee<br />
robert.marrs@aurora.org<br />
Phone: (414) 345-4940<br />
Fax: (414) 342-5326<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1977<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1867<br />
AURORA HEALTH CARE METRO, INC. DBA<br />
AURORA ST. LUKE'S SOUTH SHORE<br />
NANCYANN MARIGOMEN<br />
5900 S. LAKE DRIVE<br />
CUDAHY, WI 53110<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 489-4125<br />
Fax: (414) 489-4056<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1989<br />
10/01/2010<br />
09/30/2012<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2010 09/30/2012<br />
01/01/2012 09/30/2012<br />
10/01/2010 09/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 27 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2517<br />
AURORA MEDICAL GROUP BEHAVIORAL HEALTH<br />
SERVICES - LAKE GENEVA<br />
KATE CONNELLY<br />
146 E GENEVA SQUARE<br />
LAKE GENEVA, WI 53147<br />
County: Walworth<br />
kate.connelly@aurora.org<br />
Phone: (414) 454-6506<br />
Fax: (414) 454-6450<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/2004<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1089<br />
AURORA MEDICAL GROUP BEHAVIORAL HEALTH<br />
SERVICES<br />
KATE CONNELLY<br />
190 GARDNER AVENUE, #3<br />
BURLINGTON, WI 53105<br />
County: Rac<strong>in</strong>e<br />
kateconnelly@aurora.org<br />
Phone: (262) 763-7766<br />
Fax: (262) 763-9326<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
AURORA HEALTH CENTER - DELAVAN Tier 1<br />
1550 HOBBS DRIVE<br />
02/01/2011<br />
DELAVAN, WI 53115<br />
01/31/2013<br />
AURORA HEALTH CENTER - ELKHORN Tier 1<br />
205 E COMMERCE COURT<br />
02/01/2011<br />
ELKHORN, WI 53121<br />
01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1983<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2218<br />
AURORA MEDICAL GROUP BEHAVIORAL HEALTH<br />
SERVICES<br />
KATE CONNELLY<br />
12225 - 71ST STREET<br />
KENOSHA, WI 53142<br />
County: Kenosha<br />
No Email Address Provided<br />
Phone: (262) 948-4870<br />
Fax: (262) 948-4871<br />
Surveyor: Mark Isaacs<br />
Services<br />
AURORA MED GROUP BEHAV<br />
HLTH-WATERFORD<br />
818 FORREST<br />
WATERFORD, WI 53185<br />
02/01/2011 01/31/2013<br />
Tier 1<br />
02/01/2011<br />
01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/24/1998<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 28 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2540<br />
AURORA MEDICAL GROUP OSHKOSH<br />
RENEE RAETHER<br />
700 N. WESTHAVEN DRIVE<br />
OSHKOSH, WI 54901<br />
County: W<strong>in</strong>nebago<br />
renee.raether@aurora.org<br />
Phone: (920) 456-2030<br />
Fax: (920) 456-2025<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/2004<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1647<br />
AURORA PSYCHIATRIC HOSPITAL, INC.<br />
JAMIE LEWISTON<br />
1220 DEWEY AVENUE<br />
WAUWATOSA, WI 53213<br />
County: Milwaukee<br />
jamie.lewiston@aurora.org<br />
Phone: (414) 454-6543<br />
Fax: (414) 454-6450<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
AURORA MEDICAL GROUP OSHKOSH Tier 1<br />
855 N WESTHAVEN DR<br />
09/01/2011<br />
OSHKOSH, WI 54904<br />
08/31/2013<br />
AURORA MEDICAL GROUP OSHKOSH Tier 1<br />
1136 WESTOWNE DR<br />
09/01/2011<br />
NEENAH, WI 54956<br />
08/31/2013<br />
AURORA MEDICAL GROUP OSHKOSH Tier 2<br />
210 WISCONSIN AMERICAN DRIVE<br />
09/01/2011<br />
FOND DU LAC, WI 54935<br />
08/31/2013<br />
AURORA MEDICAL GROUP OSHKOSH Tier 1<br />
414 DOCTORS COURT<br />
09/01/2011<br />
OSHKOSH, WI 54901<br />
08/31/2013<br />
AURORA MEDICAL GROUP OSHKOSH Tier 1<br />
1242 W FOND DU LAC STREET<br />
09/01/2011<br />
RIPON, WI 54971<br />
08/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1979<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Transitional Residential DHS 75.14<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 3 DHS 40.11(2)(c)<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
NO BRANCH LOCATIONS<br />
09/01/2011 08/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 29 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1925<br />
AURORA SHEBOYGAN CLINIC<br />
TRACY LEE-JOHNSON<br />
2414 KOHLER MEMORIAL DRIVE<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
tracy.lee-johnson@aurora.org<br />
Phone: (920) 459-1494<br />
Fax: (920) 459-1483<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1986<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1835<br />
AURORA SHEBOYGAN MEMORIAL MEDICAL<br />
CENTER<br />
JAMIE LEWISTON<br />
2629 N. 7TH STREET<br />
SHEBOYGAN, WI 53083<br />
County: Sheboygan<br />
jamie.lewiston@aurora.org<br />
Phone: (920) 451-5510<br />
Fax: (920) 451-5123<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
AURORA SHEBOYGAN CLINIC Tier 1<br />
2600 KILEY WAY<br />
07/01/2012<br />
PLYMOUTH, WI 53073<br />
06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1987<br />
05/01/2012<br />
04/30/2014<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2728<br />
BAD RIVER AODA PROGRAM<br />
JOANN BARYLSKI<br />
53585 NOKOMIS RD<br />
ASHLAND, WI 54806<br />
County: Ashl<strong>and</strong><br />
AODA@badriverhealthservices.com<br />
Phone: (715) 682-7133<br />
Fax: (715) 685-2601<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2007<br />
03/01/2011<br />
02/28/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2011 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 30 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2946<br />
BALDWIN AREA MEDICAL CENTER, INC<br />
CHRISTOPHER BABBITT<br />
730 - 10TH AVENUE<br />
BALDWIN, WI 54002<br />
County: Sa<strong>in</strong>t Croix<br />
northwestcounsel<strong>in</strong>g@healthybaldw<strong>in</strong>.org<br />
Phone: (715) 684-6777<br />
Fax: (715) 684-6776<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/20/2011<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2925<br />
BARRON COUNTY DEPARTMENT OF HEALTH &<br />
HUMAN SERVICES COMMUNITY SUPPORT<br />
PROGRAM<br />
JUDY DEMERS<br />
11 E. EAU CLAIRE STREET<br />
RICE LAKE, WI 54868<br />
County: Barron<br />
david.hensley@co.barron.wi.us<br />
Phone: (715) 537-5691<br />
Fax: (715) 537-6848<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2010<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2640<br />
BARRON COUNTY DEPARTMENT OF HEALTH AND<br />
HUMAN SERVICES<br />
JUDY DEMERS<br />
330 LASALLE AVENUE, ROOM 338<br />
BARRON, WI 54812<br />
County: Barron<br />
david.hensley@co.barron.wi.us<br />
Phone: (715) 537-6341<br />
Fax: (715) 537-6848<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2006<br />
11/01/2011<br />
10/31/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 31 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2375<br />
BARRON-WASHBURN COMMUNITY SUPPORT<br />
PROGRAM<br />
BRADLEY JAHR<br />
330 E LA SALLE AVENUE #338<br />
BARRON, WI 54812<br />
County: Barron<br />
bradley.jahr@co.barron.wi.us<br />
Phone: (715) 537-5691<br />
Fax: (715) 537-6848<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/26/2002<br />
11/01/2009<br />
10/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1080<br />
BAY AREA MENTAL HEALTH CENTER<br />
BARBARA SNYDER<br />
101 THOMPSON ROAD<br />
WASHBURN, WI 54891<br />
County: Bayfield<br />
bamhc@centurytel.net<br />
Phone: (715) 373-2233<br />
Fax: (715) 373-5530<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1991<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2871<br />
BAY COUNSELING CLINIC<br />
JEANNA GRAHL<br />
50 SOUTH MADISON AVE SUITE 3<br />
STURGEON BAY, WI 54235<br />
County: Door<br />
baycounsel<strong>in</strong>g@gmail.com<br />
Phone: (920) 743-4428<br />
Fax: (920) 743-4681<br />
Surveyor: Frank Bellaire<br />
Services<br />
11/01/2009 10/31/2010<br />
BAY AREA MENTAL HEALTH CENTER Tier 1<br />
502 W MAIN ST, ROOM 303<br />
05/01/2011<br />
ASHLAND, WI 54806<br />
04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2009<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 32 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1085<br />
BEACON HOUSE<br />
MARY GERLACH<br />
166 SOUTH PARK AVENUE<br />
FOND DU LAC, WI 54936<br />
County: Fond Du Lac<br />
fwrbeacon@tds.net<br />
Phone: (920) 923-3999<br />
Fax: (920) 923-3240<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/28/1993<br />
06/01/2012<br />
05/31/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Transitional Residential DHS 75.14<br />
1087<br />
BEHAVIORAL CONSULTANTS, INC.<br />
SUSAN ZANOLA<br />
1428 N. FARWELL AVENUE, #210<br />
MILWAUKEE, WI 53202<br />
County: Milwaukee<br />
bci@core.com<br />
Phone: (414) 271-5577<br />
Fax: (414) 271-6667<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1984<br />
12/01/2008<br />
11/30/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2154<br />
BEHAVIORAL HEALTH SERVICES OF MEMORIAL<br />
MEDICAL CENTER<br />
TOM MCMULLIN<br />
1635 MAPLE LANE<br />
ASHLAND, WI 54806<br />
County: Ashl<strong>and</strong><br />
tmcmull<strong>in</strong>@ashl<strong>and</strong>mmc.com<br />
Phone: (715) 685-5400<br />
Fax: (715) 685-5102<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
06/01/2012 05/31/2014<br />
06/01/2012 05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1999<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 2 DHS 34.2<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
12/01/2008 11/30/2010<br />
ASHLAND COUNTY JAIL Tier 1<br />
221 - 7TH ST, EAST<br />
10/01/2011<br />
ASHLAND, WI 54806<br />
09/30/2013<br />
ASHLAND SCHOOL DISTRICT - MIDDLE<br />
SCHOOL<br />
Tier 1<br />
203 - 11TH STREET EAST<br />
10/01/2011<br />
ASHLAND, WI 54806<br />
09/30/2013<br />
BAYFIELD COUNTY JAIL Tier 1<br />
117 E 6TH ST<br />
10/01/2011<br />
WASHBURN, WI 54891<br />
09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 33 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2976<br />
BEHAVIORAL HEALTH SERVICES OF RACINE<br />
COUNTY<br />
MICHELLE GOGGINS<br />
1717 TAYLOR AVE<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
michelle.gogg<strong>in</strong>s@gorac<strong>in</strong>e.org<br />
Phone: (262) 638-6633<br />
Fax: (262) 638-6983<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/02/2012<br />
08/02/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2352<br />
BEHREND PSYCHOLOGY CONSULTANTS<br />
DEBORAH FUEHRER<br />
464 DALY AVENUE<br />
WISCONSIN RAPIDS, WI 54494<br />
County: Wood<br />
bpc@wctc.net<br />
Phone: (715) 423-2030<br />
Fax: (715) 423-2032<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
WESTERN RACINE COUNTY SERVICE<br />
CENTER<br />
209 NORTH MAIN ST<br />
BURLINGTON, WI 53105<br />
WESTERN RACINE COUNTY SERVICE<br />
CENTER<br />
209 NORTH MAIN ST<br />
BURLINGTON, WI 53105<br />
Tier 2<br />
08/02/2012<br />
07/31/2013<br />
Tier 2<br />
08/02/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2002<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2951<br />
BEHRENS PSYCHOTHERAPY SERVICES, LLC<br />
JENNA BEHRENS<br />
2321 E CAPITOL DRIVE, #400<br />
SHOREWOOD, WI 53211<br />
County: Milwaukee<br />
jenna@behrenspsychotherapyservices.com<br />
Phone: (262) 689-0688<br />
Fax: (262) 242-3219<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/02/2012 07/31/2013<br />
08/02/2012 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011<br />
12/01/2011<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
BEHRENS PSYCHOTHERAPY SERVICES,<br />
LLC<br />
140 S MAIN STREET<br />
THIENSVILLE, WI 53092<br />
05/01/2011 04/30/2013<br />
Tier 1<br />
12/01/2011<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 34 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2235<br />
BELL THERAPY - SOUTH 68TH STREET<br />
JILL LETIZIA<br />
2858 SOUTH 68TH STREET<br />
MILWAUKEE, WI 53219<br />
County: Milwaukee<br />
jletizia@phoenixcaresystems.com<br />
Phone: (414) 445-9180<br />
Fax: (414) 445-5995<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/2000<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
1095<br />
BELL THERAPY COMMUNITY SUPPORT<br />
PROGRAM SOUTH<br />
DOUGLAS HIGBIE<br />
634 W. MITCHELL, 1ST FLOOR<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
dhigbie@phoenixcaresystems.com<br />
Phone: (414) 383-4486<br />
Fax: (414) 383-4522<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/03/1997<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2305<br />
BELL THERAPY OUTPATIENT CLINIC<br />
RON MENDYKE<br />
6414 W. FOND DU LAC AVENUE<br />
MILWAUKEE, WI 53218<br />
County: Milwaukee<br />
rmendyke@phoenixcaresystems.com<br />
Phone: (414) 527-6940<br />
Fax: (414) 527-6971<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1987<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2011 08/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 35 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2319<br />
BELL THERAPY SERVICES MENTAL HEALTH<br />
OUTPATIENT CLINIC<br />
RONALD MENDYKE<br />
4941 W. FOND DU LAC AVENUE<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
rmendyke@phoenixcaresystems.com<br />
Phone: (414) 527-6940<br />
Fax: (414) 527-6941<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/20/2001<br />
10/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2409<br />
BELL THERAPY, INC, KENOSHA COMMUNITY<br />
SUPPORT PROGRAM<br />
ANNE JONES<br />
5500 - 8TH AVENUE<br />
KENOSHA, WI 53140<br />
County: Kenosha<br />
ajones@phoenixcaresystems.com<br />
Phone: (262) 564-0067<br />
Fax: (262) 652-1411<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2003<br />
06/01/2009<br />
05/31/2011<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1096<br />
BELL THERAPY, INC. - DAY ONE<br />
JILL LETIZIA<br />
4065 N. 35TH STREET<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
jletizia@phoenixcaresystems.com<br />
Phone: (414) 445-9180<br />
Fax: (414) 445-5995<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2010 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1987<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
NO BRANCH LOCATIONS<br />
06/01/2009 05/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2011 03/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 36 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1093<br />
BELL THERAPY, INC. COMMUNITY SUPPORT<br />
PROGRAM - NORTH<br />
DOUG HIGBIE<br />
4929 W. FOND DU LAC AVENUE<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
dhigbie@phoenixcaresystems.com<br />
Phone: (414) 871-6122<br />
Fax: (414) 871-2552<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1990<br />
04/01/2012<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1097<br />
BELLEVILLE FAMILY MEDICAL CLINIC<br />
MADONNA BINKOWSKI<br />
21 S. VINE STREET<br />
BELLEVILLE, WI 53508<br />
County: Dane<br />
No Email Address Provided<br />
Phone: (608) 424-3384<br />
Fax: (608) 424-6353<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1994<br />
07/01/2008<br />
06/30/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2759<br />
BELLIN PSYCHIATRIC CENTER - OCONTO<br />
HOSPITAL & MEDICAL CENTER<br />
STEVE DUSCHER<br />
820 ARBUTUS AVENUE<br />
OCONTO, WI 54153<br />
County: Oconto<br />
sldusc@bell<strong>in</strong>. org<br />
Phone: (920) 835-5500<br />
Fax: (920) 835-5510<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/23/2007<br />
01/01/2011<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
BELLIN PSYCHIATRIC<br />
CENTER-MARINETTE<br />
3123 SHORE DRIVE<br />
MARINETTE, WI 54143<br />
07/01/2008 06/30/2010<br />
Tier 1<br />
01/01/2011<br />
10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2011 10/31/2012<br />
01/01/2011 10/31/2012<br />
01/01/2011 10/31/2012<br />
01/01/2011 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 37 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2241<br />
BELLIN PSYCHIATRIC CENTER BEHAVIORAL<br />
HEALTH CLINIC ASHWAUBENON<br />
STEVE DUSCHER<br />
1630 COMMANCHE AVENUE<br />
GREEN BAY, WI 54313<br />
County: Brown<br />
sldusc@bell<strong>in</strong>.org<br />
Phone: (920) 431-5687<br />
Fax: (920) 431-0333<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/30/2000<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2227<br />
BELLIN PSYCHIATRIC CENTER BEHAVIORAL<br />
HEALTH CLINIC OCONTO FALLS<br />
STEVE DUSCHER<br />
833 S. MAIN STREET<br />
OCONTO FALLS, WI 54154<br />
County: Oconto<br />
sldusc@bell<strong>in</strong>.org<br />
Phone: (920) 431-5687<br />
Fax: (920) 431-0333<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
BELLIN PSYCHIATRIC<br />
CENTER-ONCOLOGY<br />
1580 COMMANCHE AVENUE<br />
GREEN BAY, WI 54313<br />
Tier 1<br />
07/01/2012<br />
06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/23/2000<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1098<br />
BELLIN PSYCHIATRIC CENTER<br />
STEVE DUSCHER<br />
301 E ST JOSEPH STREET<br />
GREEN BAY, WI 54305<br />
County: Brown<br />
sldusc@bell<strong>in</strong>.org<br />
Phone: (920) 431-5687<br />
Fax: (920) 431-0333<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1984<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Transitional Residential DHS 75.14<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 3 DHS 40.11(2)(c)<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
07/01/2012 06/30/2014<br />
BELLIN PSYCHIATRIC CENTER Tier 1<br />
575 - 4TH ST<br />
04/01/2012<br />
KEWAUNEE, WI 54216<br />
03/31/2014<br />
BELLIN PSYCHIATRIC CENTER Tier 1<br />
744 S WEBSTER AVE<br />
04/01/2012<br />
GREEN BAY, WI 54301<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 38 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2442<br />
BELLIN PSYCHIATRIC CENTER-BELLEVUE<br />
STEVE DUSCHER<br />
3263 EATON ROAD<br />
GREEN BAY, WI 54311<br />
County: Brown<br />
sldusc@bell<strong>in</strong>.org<br />
Phone: (920) 338-6830<br />
Fax: (920) 338-6819<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/10/2002<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2233<br />
BELLIN PSYCHIATRIC CENTER-PESHTIGO<br />
STEVE DUSCHER<br />
441 FRENCH STREET<br />
PESHTIGO, WI 54157<br />
County: Mar<strong>in</strong>ette<br />
sldusc@bell<strong>in</strong>.org<br />
Phone: (920) 431-5687<br />
Fax: (920) 431-0333<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
BELLIN PSYCHIATRIC<br />
CENTER-MANITOWOC<br />
3415 CUSTER STREET, #D<br />
MANITOWOC, WI 54220<br />
Tier 1<br />
11/01/2010<br />
10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/23/2000<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2284<br />
BELLIN PSYCHIATRIC CENTER-W DEPERE<br />
STEVE DUSCHER<br />
1800 LAWRENCE DRIVE<br />
DE PERE, WI 54115<br />
County: Brown<br />
sldusc@bell<strong>in</strong>.org<br />
Phone: (920) 431-5687<br />
Fax: (920) 431-0333<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/26/2001<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 39 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2198<br />
BELOIT AREA COMMUNITY HEALTH CENTER<br />
LYNN LARSEN<br />
74 ECLIPSE CENTER<br />
BELOIT, WI 53511<br />
County: Rock<br />
llarsen@bachc.com<br />
Phone: (608) 299-3309<br />
Fax: (608) 361-0312<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/2000<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1099<br />
BELOIT INNER CITY COUNCIL, INC./DIVISION OF<br />
TELLURIAN UCAN<br />
BARBARA RUCKER<br />
74 ECLIPSE CENTER<br />
BELOIT, WI 53511<br />
County: Rock<br />
Brucker@tellurian.org<br />
Phone: (608) 365-6600<br />
Fax: (608) 365-7787<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
HEAD START Tier 1<br />
221 HENRY AVENUE<br />
02/01/2011<br />
BELOIT, WI 53511<br />
01/31/2013<br />
RACINE AREA COMMUNITY HEATLH<br />
CENTER<br />
Tier 2<br />
2405 NORTHWESTERN AVENUE<br />
02/01/2011<br />
RACINE, WI 53404<br />
01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1991<br />
05/01/2009<br />
04/30/2010<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1100<br />
BELOIT MEMORIAL HOSPITAL-COUNSELING<br />
CARE CENTER<br />
GREG AMMON<br />
1969 W. HART ROAD<br />
BELOIT, WI 53511<br />
County: Rock<br />
gammon@beloitmemorialhospital.org<br />
Phone: (608) 364-5686<br />
Fax: (608) 363-5756<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1985<br />
12/01/2011<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
05/01/2009 04/30/2010<br />
JANESVILLE OCCUPATIONAL HEALTH Tier 1<br />
1409B CRESTON PARK DRIVE<br />
12/01/2011<br />
JANESVILLE, WI 53545<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011 11/30/2012<br />
12/01/2011 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 40 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1102<br />
BELWOOD LTD./BELL THERAPY<br />
RONALD MENDYKE<br />
5151 W SILVER SPRING, W WING B25<br />
MILWAUKEE, WI 53218<br />
County: Milwaukee<br />
rmendyke@phoenixcaresystems.com<br />
Phone: (414) 527-6940<br />
Fax: (414) 527-6941<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/1978<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2456<br />
BENEDICT CENTER WOMEN'S HARM REDUCTION<br />
PROGRAM<br />
DONNA HIETPAS<br />
135 W WELLS STREET, #700<br />
MILWAUKEE, WI 53203<br />
County: Milwaukee<br />
dhietpas@benedictcenter.com<br />
Phone: (414) 347-1774<br />
Fax: (414) 347-0148<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/15/2003<br />
05/01/2012<br />
12/31/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1108<br />
BLANDINE HOUSE, INC.<br />
JIM COLWIN<br />
25 N. PARK AVENUE<br />
FOND DU LAC, WI 54935<br />
County: Fond Du Lac<br />
jimcolw<strong>in</strong>@bl<strong>and</strong><strong>in</strong>ehouse.org<br />
Phone: (920) 922-9487<br />
Fax: (920) 922-9184<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/08/1991<br />
01/01/2011<br />
12/31/2012<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
05/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2011 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 41 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1111<br />
BRAY CONSULTANTS<br />
JAMES J BRAY PHD<br />
16655 W. BLUEMOUND ROAD, #300<br />
BROOKFIELD, WI 53005<br />
County: Waukesha<br />
brayconsultants@wi.rr.com<br />
Phone: (262) 821-0588<br />
Fax: (262) 821-0599<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/1992<br />
05/01/2012<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2770<br />
BREAKTHROUGH COUNSELING<br />
THOMAS THOMAS<br />
2131 S WEBSTER AVENUE<br />
GREEN BAY, WI 54301<br />
County: Brown<br />
Tthomas721@gmail.com<br />
Phone: (920) 338-0331<br />
Fax: (920) 338-0458<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
BRAY CONSULTANTS @ SUSSEX<br />
FAMILY PRACTICE<br />
N64 W24801 MAIN STREET # 104<br />
SUSSEX, WI 53089<br />
Tier 1<br />
05/01/2012<br />
04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/29/2008<br />
05/24/2010<br />
01/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1499<br />
BRIDGE POINT HEALTH, LLC<br />
WENDY ELGIN<br />
3425 SUPERIOR AVENUE<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
bphealth@bphealth.org<br />
Phone: (920) 458-5557<br />
Fax: (920) 458-2692<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/09/1994<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
05/24/2010 01/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 42 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2471<br />
BRIGHTER DAYS COUNSELING CENTER<br />
ROBERT KNOOP<br />
6815 W CAPITOL DRIVE, #305<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
brighterdayscc@wi.rr.com<br />
Phone: (414) 461-9416<br />
Fax: (414) 461-9425<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/11/2003<br />
09/01/2012<br />
08/31/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1907<br />
BROTOLOC HEALTH CARE SYSTEMS MENTAL<br />
HEALTH CLINIC<br />
LINDSAY NOLTEE<br />
2710 N TOWN HALL ROAD<br />
EAU CLAIRE, WI 54703<br />
County: Eau Claire<br />
lnoltee@brotoloc.com<br />
Phone: (715) 874-5050<br />
Fax: (715) 874-6664<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/02/1994<br />
08/01/2010<br />
07/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2615<br />
BROWN COUNTY COMMUNITY TREATMENT<br />
CENTER COMPREHENSIVE COMMUNITY<br />
SERVICES<br />
KEVIN LUNOG<br />
3150 GERSHWIN DRIVE<br />
GREEN BAY, WI 54311<br />
County: Brown<br />
lunog_kp@co.brown.wi.us<br />
Phone: (920) 391-6959<br />
Fax: (920) 391-4822<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2012 08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/25/2005<br />
09/01/2012<br />
08/31/2014<br />
Comprehensive Community Services with Telehealth DHS 36<br />
Comprehensive Community Services (CCS) DHS 36<br />
NO BRANCH LOCATIONS<br />
08/01/2010 07/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 43 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1117<br />
BROWN COUNTY COMMUNITY TREATMENT<br />
CENTER<br />
KEVIN LUNOG<br />
3150 GERSHWIN DRIVE<br />
GREEN BAY, WI 54311<br />
County: Brown<br />
lunog_kp@co.brown.wi.us<br />
Phone: (920) 391-6959<br />
Fax: (920) 391-4822<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1975<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 w/Telehealth DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2936<br />
BROWN COUNTY HUMAN SERVICES - DIVERSION<br />
JAY CHRISTIANSON<br />
3150 GERSHWIN DRIVE<br />
GREEN BAY, WI 54311<br />
County: Brown<br />
Christianson_JA@co.brown.wi.us<br />
Phone: (920) 391-4700<br />
Fax: (920) 391-4822<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
BROWN COUNTY HUMAN SVS YOUTH<br />
CLINIC<br />
11 NORTH JEFFERSON ST<br />
GREEN BAY, WI 54305<br />
Tier 2<br />
09/01/2012<br />
08/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2011<br />
02/01/2011<br />
01/31/2012<br />
CSAS-Residential Intoxication Monitor<strong>in</strong>g DHS 75.09<br />
2381<br />
BROWN COUNTY HUMAN SERVICES-CSP BROWN<br />
COUNTY COMMUNITY TREATMENT CENTER<br />
KEVIN LUNOG<br />
3150 GERSHWIN DRIVE<br />
GREEN BAY, WI 54311<br />
County: Brown<br />
lunog_kp@co.brown.wi.us<br />
Phone: (920) 391-6959<br />
Fax: (920) 391-4822<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/24/2002<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Com Support Program w/Telehealth DHS 63<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 44 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1118<br />
BURKWOOD TREATMENT CENTER<br />
MARK LANCET<br />
615 OLD MILL ROAD<br />
HUDSON, WI 54016<br />
County: Sa<strong>in</strong>t Croix<br />
mlancet@crchealth.com<br />
Phone: (715) 386-6125<br />
Fax: (715) 381-0158<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1988<br />
05/01/2012<br />
04/30/2014<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
2885<br />
BURLINGTON BEHAVIORAL HEALTH, LLC<br />
DON CROWDER PHD<br />
565 MILWAUKEE AVENUE, #3C<br />
BURLINGTON, WI 53105<br />
County: Rac<strong>in</strong>e<br />
<strong>in</strong>fo@burl<strong>in</strong>gtonbehavioralhealth.com<br />
Phone: (262) 757-0016<br />
Fax: (262) 757-0018<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/23/2009<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2630<br />
BURNETT COUNTY HEALTH AND HUMAN<br />
SERVICES DEPARTMENT/ACCESS, INC<br />
ROBERTA RUDIGER<br />
7410 COUNTY K, #280<br />
SIREN, WI 54872<br />
County: Burnett<br />
RRudiger@burnettcounty.org<br />
Phone: (715) 349-7600<br />
Fax: (715) 349-2140<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2005<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 45 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2587<br />
C.O.P.E. BEHAVIORAL SERVICES, INC.<br />
DAVID A GUYTON<br />
2821 N. 4TH STREET, #121<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
daguyton@sbcglobal.net<br />
Phone: (414) 265-5112<br />
Fax: (414) 265-4140<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/15/2005<br />
05/01/2010<br />
04/30/2012<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1119<br />
CAILLIER CLINIC, LTD.<br />
PATRICIA FEDIE<br />
505 S. DEWEY, #101<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
callierl@aol.com<br />
Phone: (715) 836-0064<br />
Fax: (715) 836-0065<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1983<br />
12/01/2011<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2641<br />
CALM HARBOR<br />
PHILIP J HARPER<br />
141 S 8TH AVENUE<br />
WEST BEND, WI 53095<br />
County: Wash<strong>in</strong>gton<br />
calmharbor@novaservices.org<br />
Phone: (262) 338-6070<br />
Fax: (262) 338-6029<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
05/01/2010 04/30/2012<br />
05/01/2010 04/30/2012<br />
CAILLIER CLINIC, LTD Tier 1<br />
320 NORTH MAIN STREET<br />
12/01/2011<br />
RICE LAKE, WI 54868<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2006<br />
02/01/2011<br />
01/31/2013<br />
CSAS-Residential Intoxication Monitor<strong>in</strong>g DHS 75.09<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2012<br />
12/01/2011 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2011 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 46 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2244<br />
CALUMET COUNTY DEPARTMENT OF HUMAN<br />
SERVICES CSP<br />
MARK MORRISON<br />
206 COURT STREET<br />
CHILTON, WI 53014<br />
County: Calumet<br />
Morrison.Mark@co.calumet.wi.us<br />
Phone: (920) 849-1400<br />
Fax: (920) 849-1468<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/2000<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Com Support Program w/Telehealth DHS 63<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1120<br />
CALUMET COUNTY DEPARTMENT OF HUMAN<br />
SERVICES<br />
MARK MORRISON<br />
206 COURT STREET<br />
CHILTON, WI 53014<br />
County: Calumet<br />
Morrison.Mark@co.calumet.wi.us<br />
Phone: (920) 849-1400<br />
Fax: (920) 849-1468<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Emergency Outpatent with Telehealth DHS 75.05<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 w/Telehealth DHS 34.3<br />
CALUMET COUNTY DEPT OF HUMAN<br />
SERVICES<br />
2306 S. ONEIDA STREET<br />
APPLETON, WI 54915<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Tier 2<br />
07/01/2012<br />
06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 47 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2674<br />
CALUMET COUNTY DEPT OF HUMAN SERVICES<br />
COMPREHENSIVE COMMUNITY SERVICES<br />
MARK MORRISON<br />
206 COURT STREET<br />
CHILTON, WI 53014<br />
County: Calumet<br />
Morrison.mark@co.calumet.wi.us<br />
Phone: (920) 849-1400<br />
Fax: (920) 849-1468<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/13/2006<br />
07/01/2011<br />
06/30/2013<br />
Comprehensive Community Services with Telehealth DHS 36<br />
Comprehensive Community Services (CCS) DHS 36<br />
1126<br />
CARE & COUNSEL, SC<br />
JOHN RADER<br />
13700 W. NATIONAL AVENUE<br />
NEW BERLIN, WI 53151<br />
County: Waukesha<br />
carecounsel@gmail.com<br />
Phone: (262) 797-7979<br />
Fax: (262) 796-9995<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1984<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2902<br />
CARE CENTER, TELLURIAN UCAN, INC<br />
VICKY RILEY<br />
4647 MORMON COULEE ROAD<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
vriley@tellurian.org<br />
Phone: (608) 519-3080<br />
Fax: (608) 519-3083<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/14/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/26/2010<br />
05/01/2011<br />
04/30/2013<br />
CSAS-Residential Intoxication Monitor<strong>in</strong>g DHS 75.09<br />
NO BRANCH LOCATIONS<br />
06/01/2011 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 48 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1127<br />
CAREER YOUTH DEVELOPMENT, INC.<br />
STERLON WHITE<br />
2603 N. MARTIN LUTHER KING DR.<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
cydoutpatient@yahoo.com<br />
Phone: (414) 263-8352<br />
Fax: (414) 264-2264<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/15/1993<br />
06/01/2011<br />
05/31/2013<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1130<br />
CASA CLARE, A DIVISION OF MOORING<br />
PROGRAMS, INC.<br />
JAMIE LEOHNIS<br />
201 S GLENRIDGE COURT<br />
APPLETON, WI 54914<br />
County: Outagamie<br />
jamie@moor<strong>in</strong>gcasa.com<br />
Phone: (920) 731-3981<br />
Fax: (920) 731-2853<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/21/1996<br />
04/01/2011<br />
03/31/2013<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Residential Intoxication Monitor<strong>in</strong>g DHS 75.09<br />
CSAS-Transitional Residential DHS 75.14<br />
2887<br />
CATALYST FOR CHANGE CONSULTANTS, LLP<br />
DONNA JULEFF<br />
317 S 2ND STREET<br />
ALMA, WI 54610<br />
County: Buffalo<br />
juleffd@nelson-tel.net<br />
Phone: (715) 495-8396<br />
Fax: (715) 285-5937<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
06/01/2011 05/31/2013<br />
06/01/2011 05/31/2013<br />
06/01/2011 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/24/2009<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2010 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 49 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1134<br />
CATHOLIC CHARITIES - WAUKESHA<br />
RICARDO CISNEROS<br />
741 N. GRAND AVENUE, #210<br />
WAUKESHA, WI 53186<br />
County: Waukesha<br />
Rcisneros@ccmke.org<br />
Phone: (414) 771-2881<br />
Fax: (414) 771-1674<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/1981<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1138<br />
CATHOLIC CHARITIES DIOCESE OF GREEN BAY,<br />
INC.<br />
KAREN JOHNSTON<br />
214 E. SUMMER STREET<br />
APPLETON, WI 54911<br />
County: Outagamie<br />
kjohnston@gbdioc.org<br />
Phone: (920) 734-2601<br />
Fax: (920) 727-1081<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
CATHOLIC CHARITIES Tier 1<br />
N88 W17658 CHRISTMAN ROAD<br />
05/01/2011<br />
MENOMONEE FALLS, WI 53051<br />
04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/26/1988<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1132<br />
CATHOLIC CHARITIES OF THE ARCHDIOCESE OF<br />
MILWAUKEE, INC.<br />
RICARDO CISNEROS<br />
2021 N. 60TH STREET<br />
MILWAUKEE, WI 53208<br />
County: Milwaukee<br />
rcisneros@ccmke.org<br />
Phone: (414) 771-2881<br />
Fax: (414) 771-1674<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
CATHOLIC CHARITIES DIOCESE OF<br />
GREEN BAY INC<br />
474 S CAMBRIDGE STREET<br />
WAUTOMA, WI 54982<br />
CATHOLIC CHARITIES DIOCESE OF<br />
GREEN BAY INC<br />
N2845 SHADOW RD<br />
WAUPACA, WI 54981<br />
CATHOLIC CHARITIES DIOCESE OF<br />
GREEN BAY INC<br />
36 BROAD ST, #200<br />
OSHKOSH, WI 54901<br />
05/01/2011 04/30/2013<br />
Tier 1<br />
02/01/2012<br />
01/31/2014<br />
Tier 1<br />
02/01/2012<br />
01/31/2014<br />
Tier 1<br />
02/01/2012<br />
01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1981<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
02/01/2012 01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 50 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1133<br />
CATHOLIC CHARITIES OF THE ARCHDIOCESE OF<br />
MILWAUKEE, INC.<br />
RICARDO CISNEROS<br />
503 WISCONSIN AVENUE<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
rcisneros@ccmke.org<br />
Phone: (920) 458-5726<br />
Fax: (920) 458-5826<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/1983<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1135<br />
CATHOLIC CHARITIES OF THE ARCHDIOCESE OF<br />
MILWAUKEE, INC.<br />
RICARDO CISNEROS<br />
1111 DOUGLAS AVENUE (MCCARTHY HALL)<br />
RACINE, WI 53402<br />
County: Rac<strong>in</strong>e<br />
rcisneros@ccmke.org<br />
Phone: (262) 637-8888<br />
Fax: (262) 637-0695<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
CATHOLIC CHARITIES ARCHDIOCESE OF<br />
MILW INC<br />
406 JEFFERSON STREET<br />
WEST BEND, WI 53090<br />
CATHOLIC CHARITIES ARCHDIOCESE OF<br />
MILW INC<br />
191 S MAIN STREET<br />
FOND DU LAC, WI 54935<br />
Tier 1<br />
05/01/2011<br />
04/30/2013<br />
Tier 1<br />
05/01/2011<br />
04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1981<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1140<br />
CATHOLIC CHARITIES, DIOCESE OF GREEN BAY,<br />
INC.<br />
TED PHERNETTON<br />
1825 RIVERSIDE DRIVE<br />
GREEN BAY, WI 54305<br />
County: Brown<br />
TPhernetton@gbdioc.org<br />
Phone: (920) 272-8234<br />
Fax: (920) 437-4067<br />
Surveyor: Frank Bellaire<br />
Services<br />
05/01/2011 04/30/2013<br />
CATHOLIC CHARITIES OF MILW - RACINE Tier 1<br />
4400 - 22ND AVENUE<br />
07/01/2012<br />
KENOSHA, WI 53144<br />
06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1988<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
07/01/2012 06/30/2014<br />
CATHOLIC CHARITIES OF GREEN BAY Tier 2<br />
844 PIERCE AVENUE, SUITE 102<br />
08/01/2012<br />
MARINETTE, WI 54143<br />
01/31/2013<br />
CATHOLIC CHARITIES OF GREEN BAY Tier 1<br />
20 SOUTH FIRST STREET<br />
02/01/2011<br />
STURGEON BAY, WI 54235<br />
06/30/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2011 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 51 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1137<br />
CATHOLIC CHARITIES, INC., CENTRAL CITY<br />
COUNSELING SERVICES<br />
JERILYN ROBINSON<br />
30 S. FRANKLIN STREET<br />
MADISON, WI 53703<br />
County: Dane<br />
jrob<strong>in</strong>son@ccmadison.org<br />
Phone: (608) 256-2358<br />
Fax: (608) 256-2350<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1979<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2348<br />
CATHOLIC CHARITIES, INC.<br />
JERILYN ROBINSON<br />
734 MADISON AVENUE<br />
FORT ATKINSON, WI 53538<br />
County: Jefferson<br />
jrob<strong>in</strong>son@ccmadison.com<br />
Phone: (920) 256-2358<br />
Fax: (608) 256-2350<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
CATHOLIC CHARITIES, BEL0IT OFFICE Tier 1<br />
2222 SHOPIERE ROAD<br />
05/01/2012<br />
BELOIT, WI 53511<br />
04/30/2014<br />
CATHOLIC CHARITIES, JANESVILLE<br />
OFFICE<br />
Tier 1<br />
2020 E MILWAUKEE AVENUE<br />
05/01/2012<br />
JANESVILLE, WI 53545<br />
04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/04/2002<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1145<br />
CEDAR CREEK FAMILY COUNSELING, INC.<br />
VICKY MURRAY<br />
9415 W. FOREST HOME AVE., #108<br />
HALES CORNERS, WI 53130<br />
County: Milwaukee<br />
cedrcoun@execpc.com<br />
Phone: (414) 427-4884<br />
Fax: (414) 427-4889<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/15/1992<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2012<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 52 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2592<br />
CENTER FOR BEHAVIORAL MEDICINE, SC<br />
NEAL MOGLOWSKY LPC<br />
250 N. SUNNYSLOPE ROAD, #128<br />
BROOKFIELD, WI 53005<br />
County: Waukesha<br />
moglowsky@sbcglobal.net<br />
Phone: (262) 782-2820<br />
Fax: (262) 782-6937<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/2011<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1152<br />
CENTER FOR FAMILY HEALING<br />
BRENDA SPINA<br />
1476 KENWOOD DRIVE<br />
MENASHA, WI 54952<br />
County: W<strong>in</strong>nebago<br />
www.centerforfamilyheal<strong>in</strong>g.net<br />
Phone: (920) 720-8872<br />
Fax: (920) 720-8873<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1990<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1153<br />
CENTER FOR HUMAN DEVELOPMENT<br />
RUTH HEBBE<br />
631 FOREST STREET<br />
WAUSAU, WI 54403<br />
County: Marathon<br />
chd@chdevelopment.org<br />
Phone: (715) 842-0944<br />
Fax: (715) 845-6477<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2011 09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1996<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
02/01/2012 01/31/2014<br />
CENTER FOR HUMAN DEVELOPMENT Tier 1<br />
2607 POST ROAD<br />
12/01/2011<br />
STEVENS POINT, WI 54481<br />
11/30/2013<br />
CENTER FOR HUMAN DEVELOPMENT Tier 1<br />
243 S CENTRAL STREET, #109<br />
12/01/2011<br />
MARSHFIELD, WI 54449<br />
11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011 11/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 53 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1155<br />
CENTER FOR LIFE & LOSS INTEGRATION<br />
JUDITH KOEPPL<br />
4123 MONONA DRIVE<br />
MADISON, WI 53716<br />
County: Dane<br />
jkoeppl@execpc.com<br />
Phone: (608) 258-7771<br />
Fax: (608) 832-6486<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1995<br />
03/01/2009<br />
02/28/2011<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2969<br />
CENTER FOR QUALITY COMMUNITY LIFE, INC.<br />
(CQCL)<br />
KATHY CARTER<br />
6830 W VILLARD AVENUE, #300<br />
MILWAUKEE, WI 53218<br />
County: Milwaukee<br />
Kcarter@cqcl.org<br />
Phone: (414) 464-0578<br />
Fax: (414) 464-1315<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012<br />
08/01/2012<br />
07/31/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2955<br />
CENTER POINT COUNSELING SERVICES<br />
COOPERATIVE<br />
SHERI HAMMOND<br />
210 AIRPORT RD, SUITE 103<br />
VIROQUA, WI 54665<br />
County: Vernon<br />
shammond@centerpo<strong>in</strong>t.coop<br />
Phone: (608) 638-7420<br />
Fax: (608) 638-7429<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2009 02/28/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011<br />
12/01/2011<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CENTER POINT COUNSELING SERVICES<br />
VERNON MANOR<br />
E7404A COUNTY ROAD BB<br />
VIROQUA, WI 54665<br />
08/01/2012 07/31/2013<br />
Tier 1<br />
02/27/2012<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011 11/30/2012<br />
12/01/2011 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 54 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2293<br />
CENTRAL WISCONSIN COUNSELING ASSOCIATES<br />
AMY GUNDERSON<br />
320 W. GRAND AVE SUITE 304A<br />
WISCONSIN RAPIDS, WI 54495<br />
County: Wood<br />
cwca@charter.net<br />
Phone: (715) 424-6960<br />
Fax: (715) 424-6963<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/2001<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2477<br />
CENTURY HOUSE<br />
DAWN ROLLING<br />
1130 NORTHVIEW ROAD<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
dawn@mtrc<strong>in</strong>c.org<br />
Phone: (262) 544-6233<br />
Fax: (262) 544-9360<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
CENTRAL WISCONSIN COUNSELING<br />
ASSOCIATES<br />
2390 - 48TH STREET SOUTH<br />
WISCONSIN RAPIDS, WI 54495<br />
CENTRAL WISCONSIN COUNSELING<br />
ASSOCIATES<br />
1216 STRONGS AVE<br />
STEVENS POINT, WI 54481<br />
Tier 1<br />
01/01/2012<br />
12/31/2013<br />
Tier 1<br />
01/17/2012<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/17/2003<br />
03/01/2012<br />
02/28/2013<br />
CSAS-Transitional Residential DHS 75.14<br />
2904<br />
CHANGING HABITS, LLC<br />
JAMES BAER<br />
2999 W SPENCER STREET, #1050<br />
APPLETON, WI 54914<br />
County: Outagamie<br />
jbaer@chang<strong>in</strong>g-habits.com<br />
Phone: (920) 570-1904<br />
Fax: (877) 673-1148<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/14/2010<br />
05/01/2012<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 55 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2464<br />
CHARIS COUNSELING, LLC<br />
LORI THOMPSON<br />
2620 W. STEWART AVENUE, #310<br />
WAUSAU, WI 54401<br />
County: Marathon<br />
ldrews@airnetisp.com<br />
Phone: (715) 848-0525<br />
Fax: (715) 848-8665<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/2003<br />
09/01/2012<br />
08/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1174<br />
CHILD & FAMILY PSYCHOLOGICAL SERVICES<br />
CLINIC<br />
NIRA SCHERZ-BUSCH<br />
437 S. YELLOWSTONE DR., #218<br />
MADISON, WI 53719<br />
County: Dane<br />
nira@charter.net<br />
Phone: (608) 288-1882<br />
Fax: (608) 288-1892<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
CHARIS COUNSELING, LLC Tier 2<br />
101 W MC MILLAN STREET, #2B<br />
09/01/2012<br />
MARSHFIELD, WI 54449<br />
08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1982<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2275<br />
CHILD AND FAMILY CONSULTANTS, INC.<br />
KEN HORN<br />
840 WILLARD DRIVE, #201<br />
GREEN BAY, WI 54304<br />
County: Brown<br />
cfc@child<strong>and</strong>familyconsultants.com<br />
Phone: (920) 497-0788<br />
Fax: (920) 497-0792<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2012 08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/20/2000<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2011 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 56 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1175<br />
CHILD AND FAMILY THERAPEUTIC SYSTEMS<br />
DALE VANDYKE<br />
4848 S. 76TH STREET, #201<br />
GREENFIELD, WI 53220<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 325-7741<br />
Fax: (414) 325-7753<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/23/1997<br />
02/01/2009<br />
01/31/2011<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1177<br />
CHILD, ADOLESCENT, FAMILY & MARRIAGE<br />
THERAPY ASSOCIATES<br />
EMMA WILLIAMS<br />
230 W WELLS ST, STE 630<br />
MILWAUKEE, WI 53203<br />
County: Milwaukee<br />
childadoltherapy@aol.com<br />
Phone: (414) 272-5005<br />
Fax: (414) 272-3760<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
CHILD AND FAMILY THERAPEUTIC<br />
SYSTEMS<br />
211 N ROCHESTER STREET<br />
MUKWONAGO, WI 53149<br />
Tier 1<br />
02/01/2009<br />
01/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1995<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2536<br />
CHILD, MARRIAGE & FAMILY THERAPY CLINIC,<br />
LLC<br />
SHARON JOHNSON-VISOR<br />
6939 MARINER DRIVE, SUITE C<br />
RACINE, WI 53406<br />
County: Rac<strong>in</strong>e<br />
lsvisor@sbcglobal.net<br />
Phone: (262) 886-8702<br />
Fax: (262) 886-8714<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2009 01/31/2011<br />
02/01/2009 01/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2004<br />
08/01/2008<br />
07/31/2010<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2008 07/31/2010<br />
08/01/2008 07/31/2010
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 57 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2417<br />
CHILDREN'S HOSPITAL OF MILWAUKEE<br />
TRACY OERTER<br />
1020 N. 12TH STREET, 5TH FLOOR<br />
MILWAUKEE, WI 53233<br />
County: Milwaukee<br />
TOerter@chw.org<br />
Phone: (414) 266-2912<br />
Fax: (414) 266-3735<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/22/2003<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1179<br />
CHILDREN'S HOSPITAL OF WISCONSIN<br />
TRACY OERTER<br />
9000 W. WISCONSIN AVENUE<br />
MILWAUKEE, WI 53201<br />
County: Milwaukee<br />
TOerter@chw.org<br />
Phone: (414) 266-2912<br />
Fax: (414) 266-3735<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1978<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
1180<br />
CHILDREN'S SERVICE SOCIETY OF WISCONSIN<br />
ANN ROLLING, PHD<br />
2405 NORTHWESTERN AVENUE #205<br />
RACINE, WI 53404<br />
County: Rac<strong>in</strong>e<br />
Ann.roll<strong>in</strong>g@cssw.org<br />
Phone: (262) 633-3591<br />
Fax: (262) 633-2619<br />
Surveyor: Mark Isaacs<br />
Services<br />
01/01/2011 12/31/2012<br />
CHILDREN'S HOSP OF WI CLINICS - NEW<br />
BERLIN<br />
4855 S MOORLAND ROAD<br />
NEW BERLIN, WI 53151<br />
Tier 1<br />
12/01/2010<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1984<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
CSSW - BURLINGTON Tier 2<br />
480 S PINE<br />
10/01/2011<br />
BURLINGTON, WI 53105<br />
09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 58 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1185<br />
CHILDREN'S SERVICE SOCIETY OF WISCONSIN<br />
LISA DOBBERKE<br />
705 S. 24TH AVENUE, #402<br />
WAUSAU, WI 54401<br />
County: Marathon<br />
lisa.dobberke@cssw.org<br />
Phone: (715) 848-1457<br />
Fax: (715) 848-2959<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/1983<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1186<br />
CHILDREN'S SERVICE SOCIETY OF WISCONSIN<br />
ANGELA WEIDEMAN<br />
2004 HIGHLAND AVENUE, #N<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
angela.weideman@cssw.org<br />
Phone: (715) 835-5915<br />
Fax: (715) 835-8112<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
BOYS & GIRLS CLUB OF THE WAUSAU<br />
AREA<br />
1710 - 2ND STREET<br />
WAUSAU, WI 54403<br />
CHILDREN'S SERVICE SOCIETY OF<br />
WI-MARSHFIELD<br />
601 S CENTRAL AVENUE, #200<br />
MARSHFIELD, WI 54449<br />
CHILDREN'S SERVICE SOCIETY OF<br />
WI-STEVENS PT<br />
1201 WATER STREET, # C<br />
STEVENS POINT, WI 54481<br />
Tier 1<br />
01/01/2012<br />
12/31/2013<br />
Tier 2<br />
01/01/2012<br />
12/31/2013<br />
Tier 2<br />
01/01/2012<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1983<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1187<br />
CHILDREN'S SERVICE SOCIETY OF WISCONSIN<br />
EDEN CHRISTMAN-DREYER<br />
620 S 76TH SREET, #120<br />
MILWAUKEE, WI 53214<br />
County: Milwaukee<br />
eden.christm<strong>and</strong>reyer@cssw.org<br />
Phone: (414) 453-1400<br />
Fax: (414) 453-2538<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1983<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CHILDREN'S SER SOC OF WI - PARK<br />
LAWN YMCA<br />
4340 N 46TH STREET<br />
MILWAUKEE, WI 53216<br />
CHILDREN'S SERV SOC OF WI<br />
(DOWNTOWN CTR)<br />
1020 NORTH 12TH STREET<br />
MILWAUKEE, WI 53223<br />
CHILDREN'S SERVICE SOCIETY OF<br />
WISCONSIN<br />
2549 NORTH 29TH STREET<br />
MILWAUKEE, WI 53210<br />
01/01/2012 12/31/2013<br />
Tier 1<br />
01/01/2012<br />
12/31/2013<br />
Tier 1<br />
01/01/2012<br />
12/31/2013<br />
Tier 1<br />
01/01/2012<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 59 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1188<br />
CHILDREN'S SERVICE SOCIETY OF WISCONSIN<br />
MAUREEN ROBBINS<br />
1716 FORDEM AVENUE<br />
MADISON, WI 53704<br />
County: Dane<br />
No Email Address Provided<br />
Phone: (608) 221-3511<br />
Fax: (608) 221-3514<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1981<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1189<br />
CHILDREN'S SERVICE SOCIETY OF WISCONSIN<br />
JOHN GREEN<br />
615 S 8TH STREET, #220<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
john.green@cssw.org<br />
Phone: (920) 458-5062<br />
Fax: (920) 451-3941<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1991<br />
12/01/2009<br />
11/30/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1193<br />
CHILDREN'S SERVICE SOCIETY OF WISCONSIN<br />
ANN ROLLING, PHD<br />
8207 - 22ND AVE SUITE 150<br />
KENOSHA, WI 53143<br />
County: Kenosha<br />
Ann.roll<strong>in</strong>g@cssw.org<br />
Phone: (262) 652-5522<br />
Fax: (262) 652-7728<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1993<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
12/01/2009 11/30/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 60 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2199<br />
CHILDYNAMICS, LLC<br />
DR ISABELLA SARDAS<br />
11904 W. NORTH AVENUE, #110<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
isardas@aol.com<br />
Phone: (414) 258-4347<br />
Fax: (414) 258-4328<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/15/2000<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 2 DHS 40.11(2)(b)<br />
2896<br />
CHIPPEWA AREA RECOVERY RESOURCE, LSS<br />
LAURIE LESSARD<br />
13 BAY STREET<br />
CHIPPEWA FALLS, WI 54729<br />
County: Chippewa<br />
Theresa.Ellison@lsswis.org<br />
Phone: (715) 726-9023<br />
Fax: (715) 726-9055<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/09/2010<br />
03/01/2011<br />
02/28/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1195<br />
CHIPPEWA COUNTY COMMUNITY SUPPORT<br />
PROGRAM<br />
SUSAN KLINGER WALLOCH<br />
711 N. BRIDGE STREET, #122<br />
CHIPPEWA FALLS, WI 54729<br />
County: Chippewa<br />
No Email Address Provided<br />
Phone: (715) 726-7788<br />
Fax: (715) 726-4560<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/12/1994<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 61 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1196<br />
CHIPPEWA COUNTY DHS COMMUNITY MENTAL<br />
HEALTH AND RECOVERY SERVICES<br />
SUE KLINGER<br />
711 N. BRIDGE STREET, RM 122<br />
CHIPPEWA FALLS, WI 54729<br />
County: Chippewa<br />
skl<strong>in</strong>ger@co.chippewa.wi.us<br />
Phone: (715) 726-7775<br />
Fax: (715) 726-4560<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1975<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2687<br />
CHRISTIAN LIFE COUNSELING, LLC<br />
DR ERIC SEYBOLD<br />
12690 W NORTH AVENUE<br />
BROOKFIELD, WI 53005<br />
County: Waukesha<br />
eseybold@christianlifecounsel<strong>in</strong>g.net<br />
Phone: (262) 785-1008<br />
Fax: (262) 785-0644<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/05/2006<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1200<br />
CINDY MILNER CLINIC<br />
CINDY MILNER<br />
410 S 3RD STREET<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
renfield49@mac.com<br />
Phone: (414) 278-8513<br />
Fax: (414) 278-0726<br />
Surveyor: Demetrius Anderson<br />
Services<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
CHRISTIAN LIFE COUNSELING, LLC Tier 1<br />
8800 W BLUEMOUND ROAD<br />
10/01/2011<br />
MILWAUKEE, WI 53226<br />
09/30/2013<br />
CHRISTIAN LIFE COUNSELING, LLC Tier 1<br />
W175 N11163 STONEWOOD DRIVE<br />
10/01/2011<br />
GERMANTOWN, WI 53022<br />
09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1984<br />
05/01/2010<br />
09/30/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
10/01/2011 09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2010 09/30/2011
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 62 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2918<br />
CITY TRANSFORMATION CLINIC NORTH<br />
THERESA ANTHONY<br />
6815 W CAPITOL DRIVE, #301<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
theresa.anthony@citytransformationltd.org<br />
Phone: (414) 616-9744<br />
Fax: (414) 455-8786<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/06/2010<br />
09/01/2011<br />
08/31/2013<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1201<br />
CLARK COUNTY COMMUNITY SERVICES<br />
HEATHER HAINZ<br />
517 COURT STREET, RM 503<br />
NEILLSVILLE, WI 54456<br />
County: Clark<br />
heather.ha<strong>in</strong>z@co.clark.wi.us<br />
Phone: (715) 743-5208<br />
Fax: (715) 743-5209<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1984<br />
03/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
1202<br />
CLARK COUNTY COMMUNITY SUPPORT<br />
PROGRAM<br />
HEATHER HAINZ<br />
W4266 STATE HIGHWAY 29<br />
OWEN, WI 54460<br />
County: Clark<br />
heather.ha<strong>in</strong>z@co.clark.wi.us<br />
Phone: (715) 743-5208<br />
Fax: (715) 743-5209<br />
Surveyor: Polly Wong<br />
Services<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
CLARK COUNTY HEALTH CARE CENTER Tier 1<br />
W4266 STATE HWY 29<br />
03/01/2011<br />
OWEN, WI 54460<br />
12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1991<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Com Support Program w/Telehealth DHS 63<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
03/01/2011 12/31/2012<br />
03/31/2011 12/31/2012<br />
03/01/2011 12/31/2012<br />
05/09/2012 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 63 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2701<br />
CLINIC FOR CHRISTIAN COUNSELING, LLC<br />
PHILIP KOESTLER<br />
505 S DEWEY, #208<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
ccc@cccwi.org<br />
Phone: (715) 832-1678<br />
Fax: (715) 832-6680<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/03/2007<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1206<br />
CLINICAL PSYCHOLOGY ASSOCIATES OF<br />
BURLINGTON<br />
DAVID W THOMPSON PHD<br />
345 MILWAUKEE AVENUE<br />
BURLINGTON, WI 53105<br />
County: Rac<strong>in</strong>e<br />
dthompson@cl<strong>in</strong>icpsych.com<br />
Phone: (262) 763-9191<br />
Fax: (262) 763-7767<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
CLINIC FOR CHRISTIAN COUNSELING,<br />
LLC<br />
12 W MARSHALL STREET, #104<br />
RICE LAKE, WI 54868<br />
Tier 1<br />
01/01/2012<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1993<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1208<br />
CLINICAL SERVICES<br />
DR MICHAEL J NELSON<br />
420 - 1ST AVENUE SOUTH<br />
WISCONSIN RAPIDS, WI 54495<br />
County: Wood<br />
No Email Address Provided<br />
Phone: (715) 424-3400<br />
Fax: (715) 424-3441<br />
Surveyor: Bradley Jahr<br />
Services<br />
CLINICAL PSYCHOLOGY ASSOC OF<br />
WATERFORD<br />
207B MILWAUKEE AVENUE<br />
WATERFORD, WI 53185<br />
01/01/2012 12/31/2013<br />
Tier 1<br />
04/01/2012<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1988<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 64 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1212<br />
COLUMBIA COUNTY COMMUNITY SUPPORT<br />
PROGRAM<br />
PAMELA J POLZER<br />
2901 HUNTERS TRAIL<br />
PORTAGE, WI 53901<br />
County: Columbia<br />
P.Polzer@pauquette.com<br />
Phone: (608) 742-5344<br />
Fax: (608) 742-4087<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/1997<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2898<br />
COLUMBIA COUNTY COMPREHENSIVE<br />
COMMUNITY SERVICES<br />
DAWN WOODARD<br />
2652 MURPHY ROAD<br />
PORTAGE, WI 53901<br />
County: Columbia<br />
dawn.woodard@co.columbia.wi.us<br />
Phone: (608) 742-9227<br />
Fax: (608) 742-9700<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2010<br />
04/01/2012<br />
03/31/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
2670<br />
COLUMBIA COUNTY DEPARTMENT OF HEALTH &<br />
HUMAN SERVICES<br />
DAWN WOODARD<br />
2652 MURPHY ROAD<br />
PORTAGE, WI 53901<br />
County: Columbia<br />
dhhs@co.columbia.wi.us<br />
Phone: (608) 742-9227<br />
Fax: (608) 742-9700<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2006<br />
11/01/2011<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 65 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2507<br />
COLUMBIA ST MARY'S BEHAVIORAL<br />
MEDICINE-MEQUON<br />
LAWRENCE MILLER<br />
13111 N PORT WASHINGTON ROAD<br />
MEQUON, WI 53097<br />
County: Ozaukee<br />
lmiller4@columbia-stmarys.org<br />
Phone: (262) 241-6127<br />
Fax: (262) 241-6132<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/02/2003<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
1870<br />
COLUMBIA ST. MARY'S BEHAVIORAL MEDICINE -<br />
MILWAUKEE<br />
LAWRENCE MILLER<br />
2323 N LAKE DRIVE, 7TH FLOOR<br />
MILWAUKEE, WI 53211<br />
County: Milwaukee<br />
lmiller4@columbia-stmarys.org<br />
Phone: (414) 291-1620<br />
Fax: (414) 291-5969<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1981<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
1215<br />
COLUMBIA ST. MARY'S HOSPITAL MILWAUKEE<br />
CAMPUS<br />
WILLIAM L. FRY<br />
2301 N LAKE DRIVE<br />
MILWAUKEE, WI 53211<br />
County: Milwaukee<br />
wfry@columbia-stmarys.org<br />
Phone: (414) 291-5520<br />
Fax: (414) 291-5521<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1982<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 66 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1873<br />
COLUMBIA ST. MARY'S OZAUKEE HOSPITAL<br />
BEHAVIORAL HEALTH UNIT<br />
BILL FRY<br />
13111 N PORT WASHINGTON RD<br />
MEQUON, WI 53097<br />
County: Ozaukee<br />
wfry@columbia-stmarys.org<br />
Phone: (414) 291-5520<br />
Fax: (262) 243-8380<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1984<br />
03/01/2012<br />
02/28/2014<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2779<br />
COMMON THREADS FAMILY RESOURCE CENTER<br />
ELLEN EGGEN<br />
5979 SIGGELKOW ROAD<br />
MC FARLAND, WI 53558<br />
County: Dane<br />
<strong>in</strong>fo@commonthreadsmadison.org<br />
Phone: (608) 838-8999<br />
Fax: (608) 838-8988<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2008<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2334<br />
COMMUNITY ADVOCATES - HORIZONS CAMPUS<br />
STACY YONKOWSKI<br />
2511 W. VINE STREET<br />
MILWAUKEE, WI 53205<br />
County: Milwaukee<br />
stacy@horizonshouse.org<br />
Phone: (414) 342-3237<br />
Fax: (414) 342-3258<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2001<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
10/01/2011 09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 67 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1220<br />
COMMUNITY CARE RESOURCES, INC.<br />
DANIEL SIMON<br />
6717 STONE GLEN ROAD<br />
MIDDLETON, WI 53562<br />
County: Dane<br />
ccr@communitycareresources.com<br />
Phone: (608) 827-7100<br />
Fax: (608) 827-7101<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/1994<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1222<br />
COMMUNITY COUNSELING CENTER OF MADISON,<br />
INC.<br />
SHARON BARGER<br />
6629 UNIVERSITY AVENUE, #209<br />
MIDDLETON, WI 53562<br />
County: Dane<br />
univavectr@yahoo.com<br />
Phone: (608) 833-5880<br />
Fax: (608) 829-3787<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1998<br />
01/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2744<br />
COMMUNITY COUNSELING SERVICES<br />
ARLENE ESLINGER<br />
16947 COUNTY HIGHWAY X<br />
CHIPPEWA FALLS, WI 54729<br />
County: Chippewa<br />
arleneesl<strong>in</strong>ger@sbcglobal.net<br />
Phone: (715) 723-1221<br />
Fax: (715) 738-1214<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/14/2007<br />
08/01/2012<br />
07/31/2014<br />
CSAS-Intervention DHS 75.16<br />
NO BRANCH LOCATIONS<br />
01/01/2012 01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 07/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 68 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1227<br />
COMMUNITY MENTAL HEALTH SERVICES, INC.<br />
BEVERLY SCHOENENBERGER<br />
1831 N. STEVENS STREET<br />
RHINELANDER, WI 54501<br />
County: Oneida<br />
No Email Address Provided<br />
Phone: (715) 365-7000<br />
Fax: (715) 365-7029<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1986<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1228<br />
COMMUNITY PSYCHOLOGICAL SERVICES OF<br />
WAUPUN, LLC<br />
ROBERT DEYOUNG<br />
1208 S. WATERTOWN STREET<br />
WAUPUN, WI 53963<br />
County: Dodge<br />
deyourn@charter.net<br />
Phone: (920) 324-4358<br />
Fax: (920) 324-4737<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
COMMUNITY MENTAL HEALTH<br />
SERVICES INC<br />
603 B EAST WALL STREET<br />
EAGLE RIVER, WI 54521<br />
COMMUNITY MENTAL HEALTH<br />
SERVICES, INC<br />
301 S LAKE STREET<br />
CRANDON, WI 54520<br />
Tier 1<br />
04/01/2011<br />
03/31/2013<br />
Tier 1<br />
04/01/2011<br />
03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1983<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2149<br />
COMMUNITY SERVICES ASSOCIATES, SC DBA<br />
PAUQUETTE CTR FOR PSYCHOLOGICAL SVS<br />
DOUGLAS C VARVIL-WELD<br />
2901 HUNTERS TRAIL<br />
PORTAGE, WI 53901<br />
County: Columbia<br />
cl<strong>in</strong>ic@pauquette.com, dcvweld@pauquette.com<br />
Phone: (608) 742-5518<br />
Fax: (608) 742-4087<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/08/1999<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
COMMUNITY SERV ASSOC DBA<br />
PAUQUETTE CTR<br />
23295 US HIGHWAY 14 WEST<br />
RICHLAND CENTER, WI 53581<br />
COMMUNITY SERV ASSOC DBA<br />
PAUQUETTE CTR<br />
1339 PARK AVENUE<br />
COLUMBUS, WI 53925<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
Tier 2<br />
07/01/2011<br />
06/30/2013<br />
Tier 2<br />
07/01/2011<br />
06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 69 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1424<br />
COMMUNITY SERVICES ASSOCIATES, SC<br />
DOUGLAS VARVIL-WELD<br />
23295 U.S. HIGHWAY 14, WEST<br />
RICHLAND CENTER, WI 53581<br />
County: Richl<strong>and</strong><br />
cl<strong>in</strong>ic@pauquette.com<br />
Phone: (608) 647-4705<br />
Fax: (608) 647-8979<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1997<br />
02/01/2008<br />
01/31/2010<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1231<br />
COMMUNITY SUPPORT CENTER OF PRICE<br />
COUNTY<br />
PAM OLSON<br />
548 N. LAKE AVENUE<br />
PHILLIPS, WI 54555<br />
County: Price<br />
commsupp@pctcnet.net<br />
Phone: (715) 339-6449<br />
Fax: (715) 339-6450<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1998<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2157<br />
COMMUNITY SUPPORT CENTER OF RUSK<br />
COUNTY<br />
PAMELA OLSON<br />
219 WEST 2ND STREET, N<br />
LADYSMITH, WI 54848<br />
County: Rusk<br />
commsupp@pctcnet.net<br />
Phone: (715) 339-6449<br />
Fax: (715) 339-6450<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2008 01/31/2010<br />
02/01/2008 01/31/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/27/1999<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2010 09/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 70 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1426<br />
COMMUNITY SUPPORT PROGAM OF THE HUMAN<br />
SERVICE CENTER<br />
DONNA SHIMECK<br />
705 E. TIMBER DRIVE<br />
RHINELANDER, WI 54501<br />
County: Oneida<br />
ds@thehumanservicecenter.org<br />
Phone: (715) 369-2215<br />
Fax: (715) 369-2214<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1980<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Com Support Program w/Telehealth DHS 63<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2939<br />
COMPASS COUNSELING WAUSAU, LLC<br />
TRACY PETERSON<br />
1202 CALLON STREET<br />
WAUSAU, WI 54401<br />
County: Marathon<br />
tracypetersonccw@gmail.com<br />
Phone: (715) 845-5493<br />
Fax: (715) 848-5645<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/25/2011<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2905<br />
COMPASS COUNSELING<br />
SARAH KRAVICK<br />
2910 NEW PINERY ROAD UNIT A<br />
PORTAGE, WI 53901<br />
County: Columbia<br />
sarahkravick@compasscounsel<strong>in</strong>g.<strong>in</strong>fo<br />
Phone: (608) 745-4900<br />
Fax: (608) 745-4990<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
06/01/2012 05/31/2014<br />
06/01/2012 05/31/2014<br />
COMPASS COUNSELING WAUSAU LLC Tier 1<br />
319 SUPERIOR ST<br />
04/23/2012<br />
ANTIGO, WI 54409<br />
03/31/2014<br />
COMPASS COUNSELING WAUSAU<br />
LLC-EAGLE RIVER<br />
Tier 1<br />
4939 ST HWY 70 W<br />
04/01/2012<br />
EAGLE RIVER, WI 54521<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2010<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 71 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2443<br />
COMPASSIONATE CARE COUNSELING (A DIV OF<br />
COMPETITIVE EDGE EMP ASSURANCE SVS)<br />
KEVIN M ORLAKIS<br />
3624 - 17TH AVENUE<br />
KENOSHA, WI 53140<br />
County: Kenosha<br />
korlakis@sbcglobal.net<br />
Phone: (262) 652-6311<br />
Fax: (262) 605-0809<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/2003<br />
06/01/2012<br />
05/31/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1233<br />
COMPREHENSIVE CLINICAL & CONSULTING<br />
SERVICES, INC.<br />
ELLIE BRADISH<br />
7161 N. PORT WASHINGTON RD<br />
MILWAUKEE, WI 53217<br />
County: Milwaukee<br />
im@izymat.com<br />
Phone: (414) 352-7682<br />
Fax: (414) 352-7625<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1982<br />
09/01/2012<br />
08/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2604<br />
COMPREHENSIVE COUNSELING SERVICES, LLC<br />
TIMOTHY J SHININGER<br />
1317 W GRAND AVENUE<br />
PORT WASHINGTON, WI 53074<br />
County: Ozaukee<br />
No Email Address Provided<br />
Phone: (262) 284-5789<br />
Fax: (262) 284-5907<br />
Surveyor: Mark Isaacs<br />
Services<br />
06/01/2012 05/31/2014<br />
CCCS @ ADVANCED PAIN MANAGEMENT Tier 1<br />
2595 DEVELOPMENT DRIVE<br />
09/01/2012<br />
GREEN BAY, WI 54311<br />
08/31/2014<br />
CCCS @ ADVANCED PAIN MANAGEMENT Tier 1<br />
9697 ST CATHERINE'S DRIVE<br />
09/01/2012<br />
PLEASANT PRAIRIE, WI 53158<br />
08/31/2014<br />
COMPREHENSIVE CLINICAL &<br />
CONSULTING SVS<br />
Tier 1<br />
4216 OLD GREEN BAY ROAD<br />
09/01/2012<br />
RACINE, WI 53403<br />
08/31/2014<br />
COMPREHENSIVE CLINICAL &<br />
CONSULTING SVS<br />
Tier 2<br />
4131 W LOOMIS RD SUITE 210<br />
09/01/2012<br />
GREENFIELD, WI 53220<br />
08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2005<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
09/01/2012 08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2010 09/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 72 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1235<br />
COMPREHENSIVE MENTAL HEALTH SERVICES,<br />
SC<br />
JACQUE HINZ<br />
5150 N PORT WASHINGTON RD #200<br />
MILWAUKEE, WI 53217<br />
County: Milwaukee<br />
compmenthealth@aol.com<br />
Phone: (414) 332-7333<br />
Fax: (414) 332-7751<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1981<br />
11/01/2010<br />
10/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2407<br />
CONNECTIONS COUNSELING<br />
SHELLY DUTCH<br />
5005 UNIVERSITY AVE STE #100<br />
MADISON, WI 53705<br />
County: Dane<br />
shelly.dutch@connectionscounsel<strong>in</strong>g.com<br />
Phone: (608) 233-2100<br />
Fax: (608) 233-2101<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2003<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
11/01/2010 10/31/2011<br />
CONNECTIONS COUNSELING Tier 1<br />
660 W WASHINGTON<br />
04/01/2011<br />
MADISON, WI 53703<br />
05/19/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 73 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1237<br />
CORNERSTONE COUNSELING SERVICES, INC.<br />
CHRISTINE TEUTEBERG<br />
16535 W. BLUEMOUND ROAD, #200<br />
BROOKFIELD, WI 53005<br />
County: Waukesha<br />
ccshelp@ccs2.com<br />
Phone: (262) 542-3255<br />
Fax: (262) 821-6180<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1993<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
CORNERSTONE COUNSELING<br />
SERVICES, INC.<br />
400 BAY VIEW ROAD, SUITE C<br />
MUKWONAGO, WI 53149<br />
CORNERSTONE COUNSELING<br />
SERVICES, INC.<br />
888 THACKERAY TRAIL, #105<br />
OCONOMOWOC, WI 53066<br />
CORNERSTONE COUNSELING<br />
SERVICES, INC.<br />
741 N GRAND AVENUE, #302<br />
WAUKESHA, WI 53186<br />
CORNERSTONE COUNSELING<br />
SERVICES, INC.<br />
4811 S 76TH STREET<br />
GREENFIELD, WI 53220<br />
CORNERSTONE COUNSELING<br />
SERVICES, INC.<br />
5555 N PORT WASHINGTON ROAD, #200<br />
GLENDALE, WI 53217<br />
CORNERSTONE COUNSELING<br />
SERVICES, INC.<br />
120 S MAIN STREET, #102<br />
JEFFERSON, WI 53549<br />
CORNERSTONE COUNSELING<br />
SERVICES, INC.<br />
279 S 17TH STREET, #10<br />
WEST BEND, WI 53095<br />
CORNERSTONE COUNSELING<br />
SERVICES, INC.<br />
10850 W PARK PLACE, #100<br />
MILWAUKEE, WI 53224<br />
Tier 2<br />
03/01/2012<br />
02/28/2014<br />
Tier 2<br />
03/01/2012<br />
02/28/2014<br />
Tier 2<br />
03/01/2012<br />
02/28/2014<br />
Tier 2<br />
03/01/2012<br />
02/28/2014<br />
Tier 2<br />
03/01/2012<br />
02/28/2014<br />
Tier 1<br />
03/01/2012<br />
02/28/2014<br />
Tier 2<br />
03/01/2012<br />
02/28/2014<br />
Tier 2<br />
03/01/2012<br />
02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 74 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1238<br />
CORNERSTONE COUNSELING SERVICES, INC.<br />
CHRISTINE TEUTEBERG<br />
4811 SOUTH 76TH STREET, #208<br />
GREENFIELD, WI 53220<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 789-1191<br />
Fax: (414) 821-6180<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/21/1997<br />
06/01/2008<br />
05/31/2010<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2047<br />
CORNERSTONE COUNSELING SERVICES, INC.<br />
CHRISTINE TEUTEBERG<br />
888 THACKERAY TRAIL, #105<br />
OCONOMOWOC, WI 53066<br />
County: Waukesha<br />
No Email Address Provided<br />
Phone: (262) 567-3563<br />
Fax: (262) 567-5451<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/18/1998<br />
12/01/2007<br />
11/30/2009<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2048<br />
CORNERSTONE COUNSELING SERVICES, INC.<br />
CHRISTINE TEUTEBERG<br />
741 N GRAND AVENUE, #302<br />
WAUKESHA, WI 53186<br />
County: Waukesha<br />
No Email Address Provided<br />
Phone: (262) 542-3255<br />
Fax: (262) 821-6180<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
06/01/2008 05/31/2010<br />
06/01/2008 05/31/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/18/1998<br />
12/01/2007<br />
11/30/2009<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
12/01/2007 11/30/2009<br />
12/01/2007 11/30/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2007 11/30/2009<br />
12/01/2007 11/30/2009
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 75 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2402<br />
CORNERSTONE COUNSELING SERVICES, INC.<br />
CHRISTINE TEUTEBERG<br />
555 BAY VIEW ROAD, #4<br />
MUKWONAGO, WI 53149<br />
County: Waukesha<br />
No Email Address Provided<br />
Phone: (262) 363-7449<br />
Fax: (262) 821-6180<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/2002<br />
11/01/2007<br />
10/31/2009<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1240<br />
COULEE COUNCIL ON ADDICTIONS, INC.<br />
LORIE LAUTZ<br />
921 WEST AVENUE SOUTH<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
cca@couleecouncil.org<br />
Phone: (608) 784-4177<br />
Fax: (608) 784-6302<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1986<br />
11/01/2011<br />
10/31/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
1241<br />
COULEE YOUTH & ADULTS CENTERS, INC<br />
STEVEN T EIDE<br />
231 COPELAND AVENUE<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
cbusse@couleecenters.org<br />
Phone: (608) 782-7152<br />
Fax: (608) 785-1241<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2007 10/31/2009<br />
11/01/2007 10/31/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1992<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Intervention DHS 75.16<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2011 03/31/2013<br />
04/13/2011 03/31/2012<br />
04/01/2011 03/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 76 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1243<br />
COUNCIL ON AODA OF WASHINGTON COUNTY<br />
MARY SIMON<br />
1625 E. WASHINGTON, #300<br />
WEST BEND, WI 53095<br />
County: Wash<strong>in</strong>gton<br />
msimon@councilonaoda.org<br />
Phone: (414) 335-6888<br />
Fax: (262) 335-6899<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1990<br />
03/01/2011<br />
02/28/2013<br />
CSAS-Intervention DHS 75.16<br />
CSAS-Prevention DHS 75.04<br />
1247<br />
COUNSELING & PSYCHOTHERAPY SERVICES<br />
LISA CALL<br />
330 SOUTH WHITNEY WAY #304<br />
MADISON, WI 53705<br />
County: Dane<br />
cps5812@att.net<br />
Phone: (608) 231-3191<br />
Fax: (608) 231-3108<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1987<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2053<br />
COUNSELING AND DEVELOPMENT CENTER, INC.<br />
COMMUNITY SUPPORT PROGRAM<br />
BRIAN FALCK<br />
171 CHESTNUT STREET<br />
PHILLIPS, WI 54555<br />
County: Price<br />
No Email Address Provided<br />
Phone: (715) 339-3048<br />
Fax: (715) 339-2436<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/1998<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 77 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1244<br />
COUNSELING AND DEVELOPMENT CENTER, INC.<br />
BRIAN FALCK<br />
171 CHESTNUT STREET<br />
PHILLIPS, WI 54555<br />
County: Price<br />
cdc@pctcnet.net<br />
Phone: (715) 339-3048<br />
Fax: (715) 339-2436<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/01/1982<br />
11/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2370<br />
COUNSELING AND TRANSITION CENTER<br />
THERON MILLS<br />
3073 S CHASE AVENUE<br />
MILWAUKEE, WI 53207<br />
County: Milwaukee<br />
ctctheronmills@gmail.com<br />
Phone: (414) 727-2780<br />
Fax: (414) 727-5883<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
COUNSELING & DEVELOPMENT CENTER Tier 1<br />
214 - 4TH AVENUE N<br />
11/01/2011<br />
PARK FALLS, WI 54552<br />
07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/30/2002<br />
06/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2802<br />
COUNSELING ASSOCIATES LLC<br />
MARIO EINSMAN<br />
115 - 5TH AVENUE SOUTH, #301<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
marioe@hbci.com<br />
Phone: (608) 785-0827<br />
Fax: (608) 785-0273<br />
Surveyor: Polly Wong<br />
Services<br />
11/01/2011 07/31/2013<br />
11/01/2011 07/31/2013<br />
COUNSELING AND TRANSITION CENTER Tier 1<br />
121 WISCONSIN AVE. STE 214<br />
04/01/2012<br />
WAUKESHA, WI 53186<br />
04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/05/2008<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
06/01/2011 04/30/2013<br />
COUNSELING ASSOCIATES LLC Tier 1<br />
111 MARKET STREET #4A<br />
06/01/2011<br />
WINONA, MN 55987<br />
05/31/2013<br />
COUNSELING ASSOCIATES LLC Tier 1<br />
1001 MC HUGH ROAD<br />
06/01/2011<br />
HOLMEN, WI 54636<br />
05/31/2013<br />
ONALASKA SCHOOL DISTRICT Tier 1<br />
1821 E MAIN STREET<br />
06/01/2011<br />
ONALASKA, WI 54650<br />
05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2011 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 78 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1250<br />
COUNSELING ASSOCIATES OF DOOR COUNTY,<br />
LLC<br />
WILLIAM G NICK<br />
620 N. 12TH AVENUE<br />
STURGEON BAY, WI 54235<br />
County: Door<br />
cadc@dcwis.com<br />
Phone: (920) 743-9554<br />
Fax: (920) 743-1591<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/16/1993<br />
06/01/2011<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2753<br />
COUNSELING CONNECTION OF MEDFORD<br />
KELLY SCHULTZ<br />
123 W STATE STREET, #4<br />
MEDFORD, WI 54451<br />
County: Taylor<br />
counsel<strong>in</strong>gconnection@tds.net<br />
Phone: (715) 748-4312<br />
Fax: (715) 748-4407<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
COUNSELING ASSOCIATES OF DOOR<br />
COUNTY<br />
3711 HWY 42<br />
FISH CREEK, WI 54212<br />
Tier 1<br />
06/01/2011<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2007<br />
11/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2077<br />
COUNSELING SPECIALISTS, LLP<br />
BETH YOUNG-VERKUILEN<br />
424A E. LONGVIEW DRIVE<br />
APPLETON, WI 54911<br />
County: Outagamie<br />
<strong>in</strong>fo@counsel<strong>in</strong>g-specialist.com<br />
Phone: (920) 882-9877<br />
Fax: (920) 882-9880<br />
Surveyor: Frank Bellaire<br />
Services<br />
CADOTT MEDICAL<br />
CENTER-COUNSELING CONNECTION<br />
322 NORTH MAIN ST<br />
CADOTT, WI 54727<br />
06/01/2011 11/30/2012<br />
06/01/2011 11/30/2012<br />
Tier 1<br />
01/13/2012<br />
08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/05/1998<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
11/01/2010 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2010 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 79 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2180<br />
COURAGE TO CHANGE RECOVERY<br />
RAE ANN WICHLACZ<br />
106 GALVIN ROAD<br />
ABBOTSFORD, WI 54405<br />
County: Clark<br />
wichlacz@tds.net<br />
Phone: (715) 223-0480<br />
Fax: (715) 223-1611<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/07/2000<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2376<br />
CRAWFORD COUNTY COMMUNITY SUPPORT<br />
PROGRAM<br />
DANIEL MCWILLIAMS<br />
225 N BEAUMONT ROAD, #326<br />
PRAIRIE DU CHIEN, WI 53821<br />
County: Crawford<br />
dmcwilliams@crawfordcountywi.org<br />
Phone: (608) 326-0256<br />
Fax: (608) 326-4395<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
COURAGE TO CHANGE RECOVERY Tier 2<br />
188 N LAKE AVENUE, PO BOX 33<br />
11/01/2011<br />
PHILLIPS, WI 54555<br />
10/31/2013<br />
COURAGE TO CHANGE RECOVERY Tier 1<br />
880 E PERKINS, #102<br />
11/01/2011<br />
MEDFORD, WI 54451<br />
10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2002<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1259<br />
CRAWFORD COUNTY HUMAN SERVICES<br />
DEPARTMENT<br />
DANIEL MCWILLIAMS<br />
225 N BEAUMONT ROAD, #326<br />
PRAIRIE DU CHIEN, WI 53821<br />
County: Crawford<br />
dmcwilliams@crawfordcountywi.org<br />
Phone: (608) 326-0256<br />
Fax: (608) 326-4395<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 2 DHS 34.2<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 80 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1260<br />
CREATIVE CONSULTING AND COUNSELING<br />
SERVICES<br />
DR JIM MORNINGSTAR<br />
4200 W GOOD HOPE ROAD<br />
MILWAUKEE, WI 53209<br />
County: Milwaukee<br />
jim@transformationsusa.com<br />
Phone: (414) 351-5770<br />
Fax: (414) 351-5760<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/1984<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1262<br />
CREDENCE THERAPY ASSOCIATES<br />
DANIEL BISHOP<br />
1-1/2 W. GENEVA STREET<br />
ELKHORN, WI 53121<br />
County: Walworth<br />
ctamanager@credencetherapy.org<br />
Phone: (262) 723-3424<br />
Fax: (262) 723-8308<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
CREATIVE CONSULTING & COUNSELING<br />
SEVICES<br />
2728 N PROSPECT<br />
MILWAUKEE, WI 53211<br />
Tier 1<br />
03/01/2012<br />
02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/19/1995<br />
12/01/2011<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2868<br />
CROSSROADS COUNSELING CENTER - CHILD<br />
DAY TREATMENT<br />
TIM PERRY<br />
778 LOIS DRIVE<br />
SUN PRAIRIE, WI 53590<br />
County: Dane<br />
tperry@crossroads73.com<br />
Phone: (608) 208-6133<br />
Fax: (608) 755-5267<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/18/2009<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2012<br />
12/01/2011 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2010 08/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 81 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1265<br />
CROSSROADS COUNSELING CENTER<br />
TIM PERRY<br />
17 S. RIVER STREET, #254<br />
JANESVILLE, WI 53548<br />
County: Rock<br />
tperry@crossroads73.com<br />
Phone: (608) 755-5260<br />
Fax: (608) 755-5267<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1977<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2772<br />
CROSSROADS COUNSELING CENTER<br />
TIM PERRY<br />
1350 N PARKER DRIVE<br />
JANESVILLE, WI 53545<br />
County: Rock<br />
TPerryCrossroads@charter.net, mcefalu@crossroad<br />
Phone: (608) 208-6133<br />
Fax: (608) 755-5267<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
CROSSROADS COUNSELING CENTER Tier 1<br />
778 LOIS DRIVE<br />
10/01/2011<br />
SUN PRAIRIE, WI 53590<br />
09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/06/2008<br />
02/01/2009<br />
01/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2219<br />
CROSSROADS COUNSELING SERVICES, LLC<br />
KAREN J. KOLTIS<br />
224 S. BROADWAY<br />
STANLEY, WI 54768<br />
County: Chippewa<br />
ccsllc@centurytel.net<br />
Phone: (715) 644-4357<br />
Fax: (715) 644-5053<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2000<br />
09/01/2011<br />
09/30/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
02/01/2009 01/31/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2011 09/30/2011<br />
09/01/2011 09/30/2011
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 82 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2766<br />
CRYSTAL LAKE COUNSELING LLC<br />
DEB SEVERSON<br />
1821 ONE-1/2 STREET<br />
COMSTOCK, WI 54826<br />
County: Barron<br />
crystallake@centurytel.net<br />
Phone: (715) 822-2980<br />
Fax: (715) 822-2205<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/2007<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2491<br />
CURRENT INITIATIVES COUNSELING SERVICE<br />
LLC<br />
LASHAWNDA DAVIS<br />
6815 WEST CAPITOL DR SUITE 207<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
C<strong>in</strong>itiatives@aol.com<br />
Phone: (414) 616-8805<br />
Fax: (414) 616-2296<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/14/2004<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2646<br />
DANE COUNTY HUMAN SERVICES<br />
DEPT./JOURNEY MENTAL HEALTH CENTER<br />
LYNN A. BRADY<br />
702 W MAIN STREET<br />
MADISON, WI 53703<br />
County: Dane<br />
lynn.brady@journeymhc.org<br />
Phone: (608) 280-2561<br />
Fax: (608) 280-2707<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2006<br />
01/01/2012<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 83 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2940<br />
DAY ONE - SILVER SPRING CENTER<br />
RONALD MENDYKE<br />
5151 WEST SILVER SPRING DRIVE<br />
MILWAUKEE, WI 53218<br />
County: Milwaukee<br />
rmendyke@phoenixcaresystems.com<br />
Phone: (414) 527-6940<br />
Fax: (414) 527-6941<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/18/2011<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
2511<br />
DEBORAH PETERMAN COUNSELING<br />
DEBORAH PETERMAN<br />
1488 E GREEN BAY STREET, #8<br />
SHAWANO, WI 54166<br />
County: Shawano<br />
No Email Address Provided<br />
Phone: (715) 524-8896<br />
Fax: (715) 524-8964<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/24/2004<br />
04/01/2008<br />
03/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1274<br />
DELTA CENTER<br />
DAVID WILTZIUS<br />
196 E. THIRD STREET<br />
FOND DU LAC, WI 54935<br />
County: Fond Du Lac<br />
Wiltziusd@deltactr.com<br />
Phone: (920) 921-3343<br />
Fax: (920) 921-0989<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/18/1989<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
04/01/2008 03/31/2010<br />
DELTA CENTER Tier 1<br />
1080 W FOND DU LAC STREET<br />
01/01/2011<br />
RIPON, WI 54971<br />
06/07/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2011 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 84 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1275<br />
DENNIS C. HILL HARM REDUCTION CENTER<br />
DAN NOWAK<br />
820 N. PLANKINTON AVENUE<br />
MILWAUKEE, WI 53203<br />
County: Milwaukee<br />
dan.nowak@arcw.org<br />
Phone: (414) 223-6810<br />
Fax: (414) 223-6810<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/11/1997<br />
03/01/2009<br />
02/28/2011<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2274<br />
DEPARTMENT OF COMMUNITY<br />
PROGRAMS-OZAUKEE COUNTY CSP<br />
MICHAEL LAPPEN<br />
121 W. MAIN STREET<br />
PORT WASHINGTON, WI 53074<br />
County: Ozaukee<br />
mlappen@co.ozaukee.wi.us<br />
Phone: (262) 238-8200<br />
Fax: (262) 238-8104<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1977<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1276<br />
DEPARTMENT OF COMMUNITY<br />
PROGRAMS-OZAUKEE COUNTY<br />
MICHAEL LAPPEN<br />
121 W. MAIN STREET<br />
PORT WASHINGTON, WI 53074<br />
County: Ozaukee<br />
mlappen@co.ozaukee.wi.us<br />
Phone: (262) 238-8145<br />
Fax: (262) 238-8104<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2009 02/28/2011<br />
03/01/2009 02/28/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1977<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 85 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2958<br />
DEROSE FAMILY COUNSELING LLC<br />
TALIA DEROSE<br />
316 5TH STREET SUITE 1<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
DeRoseFamilyCounsel<strong>in</strong>g@gmail.com<br />
Phone: (262) 498-5169<br />
Fax: (262) 634-8608<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/07/2012<br />
03/07/2012<br />
03/13/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1279<br />
DISCOVERY & RECOVERY CLINIC, INC.<br />
WADE KOSKI<br />
4402 S. 68TH STREET, #100<br />
GREENFIELD, WI 53220<br />
County: Milwaukee<br />
discovery<strong>and</strong>recovery@yahoo.com<br />
Phone: (414) 321-4411<br />
Fax: (414) 321-0552<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/09/1990<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1280<br />
DIVERSE CLINICAL SERVICES ASSOCIATES<br />
BASILISA VIRELLA<br />
633 W. WISCONSIN AVENUE, #330<br />
MILWAUKEE, WI 53202<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 347-4063<br />
Fax: (414) 347-4075<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
03/07/2012 03/13/2013<br />
DISCOVERY & RECOVERY CLINIC, INC. Tier 1<br />
4465 N OAKLAND AVENUE, #4<br />
12/01/2010<br />
SHOREWOOD, WI 53211<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/08/1998<br />
04/01/2009<br />
01/31/2011<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2009 01/31/2011
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 86 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2349<br />
DIX & GILLETTE COUNSELING SERVICES, LLP<br />
MICHAEL DIX<br />
1720 MERRILL AVENUE #401, BOX 12<br />
WAUSAU, WI 54401<br />
County: Marathon<br />
dgcounsv@dwave.net<br />
Phone: (715) 675-3888<br />
Fax: (715) 675-2988<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/2001<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2764<br />
DODGE COUNTY HUMAN SERVICES & HEALTH<br />
DEPT COMPREHENSIVE COMMUNITY SERVICES<br />
ALYSSA SCHULTZ<br />
199 HOME ROAD<br />
JUNEAU, WI 53039<br />
County: Dodge<br />
Aschultz@co.dodge.wi.us<br />
Phone: (920) 386-3516<br />
Fax: (920) 386-3812<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/11/2007<br />
12/01/2010<br />
11/30/2012<br />
Comprehensive Community Services (CCS) DHS 36<br />
2100<br />
DODGE COUNTY HUMAN SERVICES AND HEALTH<br />
DEPARTMENT CSP<br />
KIM HERMAN<br />
199 HOME ROAD<br />
JUNEAU, WI 53039<br />
County: Dodge<br />
kherman@co.dodge.wi.us<br />
Phone: (920) 386-3500<br />
Fax: (920) 386-3812<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1999<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 87 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1282<br />
DODGE COUNTY HUMAN SERVICES AND HEALTH<br />
DEPARTMENT<br />
ALYSSA SCHULTZ<br />
199 HOME ROAD<br />
JUNEAU, WI 53039<br />
County: Dodge<br />
aschultz@co.dodge.wi.us<br />
Phone: (920) 386-3500<br />
Fax: (920) 386-3812<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1975<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2688<br />
DOMINION BEHAVIORAL HEALTH SERVICES, LLC<br />
FRANCINE DIXON<br />
W132 N6303 MARACH ROAD<br />
MENOMONEE FALLS, WI 53051<br />
County: Waukesha<br />
franc<strong>in</strong>edixon@dom<strong>in</strong>ionllc.org<br />
Phone: (262) 751-7507<br />
Fax: (262) 252-7567<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2006<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2159<br />
DOOR COUNTY DEPARTMENT OF COMMUNITY<br />
PROGRAMS COMMUNITY SUPPORT PROGRAM<br />
SHERYL FLORES<br />
421 NEBRASKA STREET<br />
STURGEON BAY, WI 54235<br />
County: Door<br />
dcp@co.door.wi.us<br />
Phone: (920) 746-2345<br />
Fax: (920) 746-2439<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1999<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2011 03/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 88 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1283<br />
DOOR COUNTY DEPARTMENT OF COMMUNITY<br />
PROGRAMS<br />
TINA MARIE BAETEN<br />
421 NEBRASKA STREET<br />
STURGEON BAY, WI 54235<br />
County: Door<br />
commprog@co.door.wi.us<br />
Phone: (920) 746-2345<br />
Fax: (920) 746-2439<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1978<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2964<br />
DOUGLAS CO DEPT HLTH & HUMAN SVS/HUMAN<br />
DEVELOPMENT CTR<br />
STEVEN ENGLESON<br />
1500 N 34TH STREET, #200<br />
SUPERIOR, WI 54880<br />
County: Douglas<br />
steve.engleson@hdchrc.org<br />
Phone: (715) 392-8216<br />
Fax: (715) 392-6055<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2010<br />
07/01/2010<br />
06/30/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 2 DHS 34.2<br />
2847<br />
DOUGLAS COUNTY DEPARTMENT OF HEALTH<br />
AND HUMAN SERVICES<br />
DAVE LONGSDORF<br />
1316 N 14TH STREET SUITE 400<br />
SUPERIOR, WI 54880<br />
County: Douglas<br />
dave.longsdorf@douglascountywi.org<br />
Phone: (715) 395-1304<br />
Fax: (715) 395-1370<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/06/2009<br />
01/01/2011<br />
12/31/2012<br />
CSAS-Intervention DHS 75.16<br />
NO BRANCH LOCATIONS<br />
07/01/2010 06/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2011 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 89 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2659<br />
DR. STRESS & ASSOCIATES, LLC<br />
BRIAN A STRESS PSY D<br />
5840 ARNDT ROAD, #3<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
bstress@drstressassociates.com<br />
Phone: (715) 833-7111<br />
Fax: (715) 833-0454<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/28/2006<br />
10/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2064<br />
DULUTH DETOXIFICATION CENTER<br />
TINA SILVERNESS-ZINMER<br />
1402 E. SUPERIOR STREET<br />
DULUTH, MN 55802<br />
County/State: Sa<strong>in</strong>t Louis, MN<br />
T<strong>in</strong>a@cadt.org<br />
Phone: (218) 529-3426<br />
Fax: (218) 529-3440<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1998<br />
11/01/2010<br />
10/31/2012<br />
CSAS-Medically Monitored Residential Detox DHS 75.07<br />
1287<br />
DUNN COUNTY DEPARTMENT OF HUMAN<br />
SERVICES BEHAVIORAL HEALTH SERVICES<br />
VICKI RADMANN<br />
808 MAIN STREET<br />
MENOMONIE, WI 54751<br />
County: Dunn<br />
vradmann@co.dunn.wi.us<br />
Phone: (715) 231-2706<br />
Fax: (715) 232-5987<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1981<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 90 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2055<br />
DUNN COUNTY DEPARTMENT OF HUMAN<br />
SERVICES COMMUNITY SUPPORT PROGRAM<br />
TIFFANY JAEGER<br />
808 MAIN STREET<br />
MENOMONIE, WI 54751<br />
County: Dunn<br />
tjaeger@co.dunn.wi.us<br />
Phone: (715) 232-1116<br />
Fax: (715) 232-5987<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/1998<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2731<br />
EASTLAKE COUNSELING/CONSULTING II<br />
MARY BETH SHAFFER<br />
135 W WELLS STREET #226<br />
MILWAUKEE, WI 53203<br />
County: Milwaukee<br />
exymil@sbcglobal.net<br />
Phone: (414) 272-0123<br />
Fax: (414) 272-3498<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/18/2007<br />
04/18/2007<br />
04/30/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1292<br />
EAU CLAIRE ACADEMY, DIVISION OF CLINICARE<br />
CORPORATION<br />
VERA MATTER<br />
550 N. DEWEY STREET<br />
EAU CLAIRE, WI 54703<br />
County: Eau Claire<br />
eauclaire<strong>in</strong>fo@cl<strong>in</strong>icarecorp.com<br />
Phone: (715) 834-6681<br />
Fax: (715) 834-9954<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
06/01/2011 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1994<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Transitional Residential DHS 75.14<br />
CSAS-Transitional Residential with Telehealth HFS 75.14<br />
NO BRANCH LOCATIONS<br />
04/18/2007 04/30/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2011 02/28/2013<br />
10/18/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
10/18/2011 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 91 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1293<br />
EAU CLAIRE COUNTY DEPARTMENT OF HUMAN<br />
SERVICES CSP<br />
RON HON<br />
721 OXFORD AVENUE<br />
EAU CLAIRE, WI 54703<br />
County: Eau Claire<br />
Ron.Hon@co.eau-claire.wi.us<br />
Phone: (715) 839-6290<br />
Fax: (715) 831-5783<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1990<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2815<br />
EAU CLAIRE COUNTY DEPARTMENT OF HUMAN<br />
SERVICES<br />
ROY SARGEANT<br />
721 OXFORD AVENUE<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
Jen.Moe@co.eau-claire.wi.us<br />
Phone: (715) 839-1200<br />
Fax: (715) 831-5658<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/09/2008<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2537<br />
EAU CLAIRE METRO TREATMENT CENTER<br />
MARCY HURLBURT<br />
2000 OXFORD AVENUE, NORTH BLDG 2<br />
EAU CLAIRE, WI 54703<br />
County: Eau Claire<br />
eauclairemetro@cmglp.com<br />
Phone: (715) 834-1078<br />
Fax: (715) 834-1218<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/16/2004<br />
12/01/2011<br />
11/30/2012<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
09/01/2011 08/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011 11/30/2012<br />
12/01/2011 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 92 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2956<br />
EBB TIDE THERAPY<br />
SHANNON O'BRIEN<br />
2821 N 4TH STREET RM 209<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
shann4455@wi.rr.com<br />
Phone: (414) 372-7212<br />
Fax: (414) 446-4354<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/2012<br />
02/01/2012<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2853<br />
ECLIPSE COUNSELING, LLC<br />
MARTIN KEANE<br />
100 RIVER PLACE, #260<br />
MONONA, WI 53716<br />
County: Dane<br />
eclipse0443@att.net<br />
Phone: (608) 221-2265<br />
Fax: (608) 221-2586<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/08/2009<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2733<br />
EDUCATIONAL SOLUTIONS, INC<br />
KRISTIN WEGNER<br />
1802 WARDEN STREET<br />
EAU CLAIRE, WI 54703<br />
County: Eau Claire<br />
krist<strong>in</strong>@educational--solutions.com<br />
Phone: (715) 552-1620<br />
Fax: (715) 552-2734<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2012 01/31/2013<br />
02/01/2012 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/29/2007<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 93 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1297<br />
ELMBROOK FAMILY COUNSELING CENTER<br />
HOWARD J HAVEN, PHD<br />
12690 W NORTH AVENUE<br />
BROOKFIELD, WI 53005<br />
County: Waukesha<br />
<strong>in</strong>fo@elmbrookfamilycounsel<strong>in</strong>gcenter.com<br />
Phone: (262) 785-9188<br />
Fax: (262) 785-0644<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1978<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1299<br />
ELMERGREEN ASSOCIATES, INC.<br />
DENNIS ELMERGREEN<br />
114 GRAND AVENUE<br />
WAUSAU, WI 54403<br />
County: Marathon<br />
No Email Address Provided<br />
Phone: (715) 845-7175<br />
Fax: (715) 845-7142<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/05/1992<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2953<br />
EMPATHETIC COUNSELING SERVICES INC.<br />
TANYA BROUGHTON LEWIS<br />
5501 W BURLEIGH ST<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
empatheticcounsel<strong>in</strong>g@gmail.com<br />
Phone: (414) 828-5617<br />
Fax: (414) 332-2523<br />
Surveyor: Demetrius Anderson<br />
Services<br />
04/01/2011 03/31/2013<br />
ELMERGREEN ASSOCIATES, INC Tier 2<br />
607 E ELIZABETH STREET<br />
11/01/2011<br />
SHAWANO, WI 54166<br />
10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011<br />
12/01/2011<br />
11/30/2012<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 11/30/2012<br />
12/01/2011 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 94 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1301<br />
EMPLOYEE RESOURCE CENTER, INC.<br />
JAMES PECARD III<br />
1511 W. MAIN AVENUE, #100<br />
DE PERE, WI 54115<br />
County: Brown<br />
jpecard@assisterc.com<br />
Phone: (920) 403-7600<br />
Fax: (920) 403-7360<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1989<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2800<br />
EMPOWERMENT CLINIC<br />
MICHAEL BRAXTON<br />
6001 W CENTER ST SUITE 100<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
mbraxton@empowermentcl<strong>in</strong>ic.com<br />
Phone: (414) 763-1757<br />
Fax: (414) 449-4850<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/28/2008<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1303<br />
ENCOMPASS-EFFECTIVE MENTAL HEALTH<br />
SERVICES, INC<br />
LAURA SCHULZ<br />
1011 N MAYFAIR ROAD, #304<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
encompas@msn.com<br />
Phone: (414) 453-8380<br />
Fax: (414) 443-1635<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1993<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2010 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 95 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2968<br />
ESPRIT COUNSELING AND CONSULTING<br />
KERRIE JO LARSON<br />
40 JEWELERS PARK DRIVE<br />
NEENAH, WI 54956<br />
County: W<strong>in</strong>nebago<br />
Kerrie@espritcounsel<strong>in</strong>g.com<br />
Phone: (920) 720-6000<br />
Fax: (920) 720-9980<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/26/2012<br />
07/26/2012<br />
06/30/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1628<br />
ESSENTIA HEALTH DULUTH DBA SMDC MEDICAL<br />
CENTER<br />
THOMAS JENSEN<br />
502 EAST SECOND STREET<br />
DULUTH, MN 55811<br />
County/State: Sa<strong>in</strong>t Louis, MN<br />
Thomas.Jensen@Essentiahealth.org<br />
Phone: (218) 786-3910<br />
Fax: (218) 722-0373<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1987<br />
12/01/2010<br />
11/30/2012<br />
CSAS-Medically Managed Inpatient Treatment DHS 75.10<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 2 DHS 40.11(2)(b)<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2083<br />
ESSENTIA HEALTH DULUTH DBA SMDC MEDICAL<br />
CENTER<br />
THOMAS JENSEN<br />
615 PECAN AVENUE<br />
DULUTH, MN 55811<br />
County/State: Sa<strong>in</strong>t Louis, MN<br />
Thomas.Jensen@Essentia<strong>Health</strong>.org<br />
Phone: (218) 786-1356<br />
Fax: (218) 786-5919<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/26/2012 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1998<br />
12/01/2010<br />
11/30/2012<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2011<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2011
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 96 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2570<br />
EULOPIA FAMILY SERVICES, INC.<br />
MARICA TIPTON<br />
2125 DERRIN LANE<br />
BROOKFIELD, WI 53045<br />
County: Waukesha<br />
tiptonm@matc.edu<br />
Phone: (414) 610-9935<br />
Fax: (262) 641-9768<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/18/2005<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2836<br />
EVERGREEN FAMILY FOCUS<br />
NANA N CISLER<br />
2475 UNIVERSITY WAY<br />
GREEN BAY, WI 54304<br />
County: Brown<br />
arttherapist@peoplepc.com<br />
Phone: (920) 469-1201<br />
Fax: (920) 469-3404<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/07/2008<br />
11/07/2008<br />
11/30/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2695<br />
EXODUS PREVENTION SERVICES, GENESIS<br />
SOCIAL SERVICES CORPORATION<br />
PAT CARRUTHERS<br />
313 W BELTLINE HIGHWAY, #153<br />
MADISON, WI 53713<br />
County: Dane<br />
Pat@gecmadison.com<br />
Phone: (608) 257-6152<br />
Fax: (608) 255-2406<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2012 01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2006<br />
01/01/2011<br />
12/31/2012<br />
CSAS-Intervention DHS 75.16<br />
CSAS-Prevention DHS 75.04<br />
NO BRANCH LOCATIONS<br />
11/07/2008 11/30/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 97 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2598<br />
EXODUS TRANSITIONAL CARE FACILITY, INC.<br />
CHARLES SCHRAUTH<br />
1421 FOND DU LAC AVENUE<br />
KEWASKUM, WI 53040<br />
County: Sheboygan<br />
<strong>in</strong>fo@exodus-house.org<br />
Phone: (262) 626-4166<br />
Fax: (262) 626-8431<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/2005<br />
01/01/2012<br />
12/31/2012<br />
CSAS-Transitional Residential DHS 75.14<br />
2493<br />
FAMILIES FIRST COUNSELING, LLC<br />
CATHERINE HAYMAN<br />
23758 STATE ROAD 35<br />
SIREN, WI 54872<br />
County: Burnett<br />
ffcc@sirentel.net<br />
Phone: (715) 349-8913<br />
Fax: (715) 349-8981<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/08/2004<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2699<br />
FAMILY AND CHILDREN'S CENTER COMMUNITY<br />
SUPPORT PROGRAM - LA CROSSE<br />
MIKE BOEHM<br />
1707 MAIN STREET<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
Mboehm@fccnetwork.org<br />
Phone: (608) 785-0001<br />
Fax: (608) 785-0002<br />
Surveyor: Polly Wong<br />
Services<br />
01/01/2012 12/31/2012<br />
FAMILIES FIRST COUNSELING, LLC Tier 1<br />
463 NORTH AVENUE E<br />
02/01/2011<br />
GRANTSBURG, WI 54840<br />
01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/12/2006<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 98 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2492<br />
FAMILY AND CHILDREN'S CENTER JACKSON<br />
COUNTY COMMUNITY SUPPORT PROGRAM<br />
MIKE BOEHM<br />
409 COUNTY ROAD R<br />
BLACK RIVER FALLS, WI 54615<br />
County: Jackson<br />
mboehm@fccnetwork.org<br />
Phone: (715) 284-9477<br />
Fax: (715) 284-5547<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/2004<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1317<br />
FAMILY AND CHILDREN'S CENTER, INC.<br />
COMMUNITY SUPPORT PROGRAM<br />
KATHY ROHR-NINMER<br />
1321 N MAIN ST<br />
VIROQUA, WI 54665<br />
County: Vernon<br />
kn<strong>in</strong>mer@fccnetwork.org<br />
Phone: (608) 637-7052<br />
Fax: (608) 637-8500<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1996<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1315<br />
FAMILY AND CHILDREN'S CENTER<br />
MIKE BOEHM<br />
1707 MAIN STREET<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
mboehm@fccnetwork.org<br />
Phone: (608) 785-0001<br />
Fax: (608) 785-0002<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1994<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
05/01/2011 04/30/2013<br />
FAMILY AND CHILDREN'S CENTER Tier 2<br />
1321 NORTH MAIN ST<br />
01/20/2012<br />
VIROQUA, WI 54665<br />
10/31/2012<br />
FAMILY AND CHILDREN'S CENTER Tier 1<br />
HWY 14 NORTH<br />
01/20/2012<br />
VIROQUA, WI 54665<br />
10/31/2012<br />
FAMILY AND CHILDREN'S CENTER Tier 2<br />
409 COUNTY RD R<br />
01/20/2012<br />
BLACK RIVER FALLS, WI 54615<br />
10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 99 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1319<br />
FAMILY COUNSELING CENTER, LLC<br />
MARY NERVIG<br />
8112 W. BLUEMOUND ROAD, #106<br />
WAUWATOSA, WI 53213<br />
County: Milwaukee<br />
mznervig@msn.com<br />
Phone: (414) 258-5523<br />
Fax: (414) 431-1071<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/1990<br />
02/01/2009<br />
01/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1321<br />
FAMILY COUNSELING SERVICES<br />
ANDREW BENEDETTO<br />
903 SECOND STREET<br />
WAUSAU, WI 54403<br />
County: Marathon<br />
ABenedetto@familycounsel<strong>in</strong>gservices.org<br />
Phone: (715) 842-3346<br />
Fax: (715) 842-3344<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1979<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1124<br />
FAMILY CRISIS CENTER - CAP SERVICES<br />
MARCIA ZIMBAUER<br />
1616 W. RIVER DRIVE<br />
STEVENS POINT, WI 54481<br />
County: Portage<br />
mzimbauer@capmail.org<br />
Phone: (715) 343-7102<br />
Fax: (715) 343-7176<br />
Surveyor: Bradley Jahr<br />
Services<br />
02/01/2009 01/31/2010<br />
FAMILY COUNSELING SERVICES Tier 1<br />
726 E SECOND STREET<br />
01/01/2012<br />
MERRILL, WI 54452<br />
12/31/2013<br />
THE WOMEN'S COMMUNITY Tier 1<br />
3200 HILLTOP AVE<br />
09/01/2012<br />
WAUSAU, WI 54401<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1998<br />
04/01/2009<br />
01/31/2011<br />
CSAS-Emergency Outpatient DHS 75.05<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 2 DHS 34.2<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2009 01/31/2011<br />
04/01/2009 01/31/2011
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 100 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2903<br />
FAMILY INNOVATIONS, INC<br />
CHERYL LERFALD<br />
2115B COUNTY ROAD D, EAST<br />
MAPLEWOOD, MN 55109<br />
County/State: Ramsey, MN<br />
clerflad@family<strong>in</strong>novations.com<br />
Phone: (651) 748-5019<br />
Fax: (651) 773-7591<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/18/2010<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2692<br />
FAMILY OPTIONS COUNSELING, LLC<br />
KIMBERLY YOUNG<br />
3015 N 114TH STREET<br />
WAUWATOSA, WI 53222<br />
County: Milwaukee<br />
kyoung@familyoptions.com<br />
Phone: (414) 431-4444<br />
Fax: (414) 431-0858<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
FAMILY INNOVATIONS, INC Tier 2<br />
131 CARMICHAEL<br />
05/01/2011<br />
HUDSON, WI 54016<br />
04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/02/2006<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1325<br />
FAMILY RESOURCE CENTER<br />
LINDA DANIELS<br />
533 PEACE PIPE ROAD<br />
LAC DU FLAMBEAU, WI 54538<br />
County: Vilas<br />
ldaniels@pchcl<strong>in</strong>ic.com<br />
Phone: (715) 588-1511<br />
Fax: (715) 588-3903<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1988<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 101 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1326<br />
FAMILY RESOURCES ASSOCIATES, INC.<br />
JANICE SCHMIDT<br />
1315 W. MAIN STREET<br />
WATERTOWN, WI 53094<br />
County: Jefferson<br />
jschmidt@familyresources<strong>in</strong>c.com<br />
Phone: (920) 261-4100<br />
Fax: (920) 261-8801<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1993<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2554<br />
FAMILY SERVICE ASSOCIATES, SC DBA<br />
PAUQUETTE CTR FOR PSYCHOLOGICAL<br />
SERVICES<br />
TOM HAYES<br />
1002 LINCOLN AVENUE<br />
BARABOO, WI 53913<br />
County: Sauk<br />
bus<strong>in</strong>ess@pauquette.ort<br />
Phone: (608) 356-9055<br />
Fax: (608) 356-5457<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
FAMILY RESOURCES ASSOCIATES INC Tier 2<br />
331 N MAIN STREET<br />
11/01/2010<br />
LAKE MILLS, WI 53551<br />
10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2004<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
1327<br />
FAMILY SERVICE OF MADISON, INC.<br />
ANN LEWIS<br />
128 E. OLIN AVENUE, #100<br />
MADISON, WI 53713<br />
County: Dane<br />
<strong>in</strong>fo@fsmad.org<br />
Phone: (608) 316-1129<br />
Fax: (608) 252-1333<br />
Surveyor: William Rohner<br />
Services<br />
FAMILY SERVICE ASSOCIATES SC DBA<br />
PAUQUETTE<br />
710 N WEBB AVE<br />
REEDSBURG, WI 53959<br />
FAMILY SERVICE ASSOCIATES SC DBA<br />
PAUQUETTE<br />
50 PRAIRIE AVENUE<br />
PRAIRIE DU SAC, WI 53578<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
Tier 2<br />
08/01/2011<br />
07/31/2013<br />
Tier 2<br />
08/01/2011<br />
07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1977<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 102 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1339<br />
FAMILY SERVICE OF RACINE, INC.<br />
JACK WOOD<br />
420 SEVENTH STREET<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
dir.fsrac<strong>in</strong>e@att.net<br />
Phone: (262) 634-2391<br />
Fax: (262) 634-5342<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1983<br />
01/01/2012<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1340<br />
FAMILY SERVICE OF WAUKESHA<br />
LAURA CHERONE<br />
101 W BROADWAY, 2ND FLOOR<br />
WAUKESHA, WI 53186<br />
County: Waukesha<br />
<strong>in</strong>fo@fswaukesha.org<br />
Phone: (262) 547-5567<br />
Fax: (262) 547-1608<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1977<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1329<br />
FAMILY SERVICES OF NORTHEAST WISCONSIN,<br />
INC.<br />
LOIS MISCHLER<br />
300 CROOKS STREET<br />
GREEN BAY, WI 54301<br />
County: Brown<br />
lmischler@familyservicesnew.org<br />
Phone: (920) 436-6800<br />
Fax: (920) 432-5966<br />
Surveyor: Frank Bellaire<br />
Services<br />
01/01/2012 12/31/2012<br />
FAMILY SERVICE OF WAUKESHA Tier 1<br />
726 N EAST AVENUE<br />
02/01/2012<br />
WAUKESHA, WI 53186<br />
01/31/2014<br />
FAMILY SERVICE OF WAUKESHA Tier 1<br />
119A SILVER LAKE STREET<br />
02/01/2012<br />
OCONOMOWOC, WI 53066<br />
01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/12/1996<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
FAMILY SERVICES OF NORTHEAST<br />
WISCONSIN<br />
3430 SPIRIT WAY<br />
GREEN BAY, WI 54304<br />
02/01/2012 01/31/2014<br />
Tier 1<br />
04/01/2012<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 103 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1332<br />
FAMILY SERVICES OF NORTHEAST WISCONSIN,<br />
INC.<br />
JODY GREENWELL<br />
626 S. IRWIN AVENUE<br />
GREEN BAY, WI 54301<br />
County: Brown<br />
jgreenwell@familyserviesnew.org<br />
Phone: (920) 433-3372<br />
Fax: (920) 433-3383<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/1984<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
1331<br />
FAMILY SERVICES OF SOUTHERN WISCONSIN<br />
AND NORTHERN ILLINOIS, INC.<br />
JENNIFER FRUIN<br />
423 BLUFF STREET<br />
BELOIT, WI 53511<br />
County: Rock<br />
Jfru<strong>in</strong>@familyservices1.org<br />
Phone: (608) 365-1244<br />
Fax: (608) 365-4097<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1981<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1343<br />
FAMILY SOLUTIONS ASSOCIATES, LLP<br />
SUE KAUFMANN<br />
N9710 STATE HWY 108<br />
MELROSE, WI 54642<br />
County: Jackson<br />
Sue800@gmail.com<br />
Phone: (507) 450-6397<br />
Fax: (507) 961-0359<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1997<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
06/01/2012 05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 104 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1345<br />
FAMILY TREE MENTAL HEALTH CLINIC<br />
LOIS HADLEY<br />
508 CAMPUS STREET, #6<br />
MILTON, WI 53563<br />
County: Rock<br />
familytree@centurytel.net<br />
Phone: (608) 868-5122<br />
Fax: (608) 868-5155<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1998<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1342<br />
FAMILYMEANS<br />
PATRICIA ROGERS<br />
1875 NORTHWESTERN AVENUE, S.<br />
STILLWATER, MN 55082<br />
County/State: Wash<strong>in</strong>gton, MN<br />
familymeans@familymeans.org<br />
Phone: (651) 439-4840<br />
Fax: (651) 439-4894<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1989<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1348<br />
FIRST THINGS FIRST COUNSELING &<br />
CONSULTING<br />
ED RAMSEY<br />
2519 N HILLCREST PKWY STE 201<br />
ALTOONA, WI 54720<br />
County: Eau Claire<br />
fth<strong>in</strong>gsf@sbcglobal.net<br />
Phone: (715) 832-8432<br />
Fax: (715) 832-5007<br />
Surveyor: Polly Wong<br />
Services<br />
03/01/2011 02/28/2013<br />
FAMILYMEANS Tier 1<br />
2217 VINE STREET, #105<br />
05/01/2012<br />
HUDSON, WI 54016<br />
04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1990<br />
08/01/2012<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 07/31/2013<br />
08/01/2012 07/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 105 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2473<br />
FOKUS FAMILY SERVICES<br />
ELZORA COLLINS<br />
2821 N. 4TH STREET, #139<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
fokusfamilyservices@yahoo.com<br />
Phone: (414) 264-4217<br />
Fax: (414) 264-4218<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/28/2003<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2680<br />
FOND DU LAC COUNTY DEPARTMENT OF<br />
COMMUNITY PROGRAMS CCS<br />
REBECCA HOLZMAN<br />
459 E FIRST STREET<br />
FOND DU LAC, WI 54935<br />
County: Fond Du Lac<br />
rebecca.holzman@fdlco.wi.gov<br />
Phone: (920) 929-7123<br />
Fax: (920) 929-3129<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/18/2006<br />
08/01/2011<br />
07/31/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
1350<br />
FOND DU LAC COUNTY DEPARTMENT OF<br />
COMMUNITY PROGRAMS<br />
REBECCA HOLZMAN<br />
459 E. FIRST STREET<br />
FOND DU LAC, WI 54935<br />
County: Fond Du Lac<br />
community.programs@fdlco.wi.gov<br />
Phone: (920) 929-3500<br />
Fax: (920) 929-3129<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1978<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 106 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1351<br />
FOREST COUNTY POTAWATOMI BEHAVIORAL<br />
HEALTH DEPARTMENT<br />
BETTY THUNDER<br />
5409 EVERYBODYS ROAD<br />
CRANDON, WI 54520<br />
County: Forest<br />
betty@fcpototawotmi.com<br />
Phone: (715) 478-4332<br />
Fax: (715) 478-4493<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/1994<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
1309<br />
FORT HEALTH CARE BEHAVIORAL HEALTH<br />
JESSIE MUELLER<br />
509 MCMILLEN STREET<br />
FORT ATKINSON, WI 53538<br />
County: Jefferson<br />
jessie.mueller@forthc.com<br />
Phone: (920) 563-9542<br />
Fax: (920) 568-6047<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1991<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2785<br />
FORWARD CHOICES LLC<br />
MICHAEL WALLNER<br />
6040 W LISBON AVENUE, #103<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
forwardchoicesLLC@att.net<br />
Phone: (414) 442-1751<br />
Fax: (414) 442-1775<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
CENTER FOR BEHAVIORAL HEALTH Tier 1<br />
1461 W MAIN ST<br />
02/01/2012<br />
WHITEWATER, WI 53190<br />
01/31/2014<br />
CENTER FOR BEHAVIORAL HEALTH Tier 1<br />
402 S GAMMON PL #300<br />
02/01/2012<br />
MADISON, WI 53719<br />
01/31/2014<br />
FORT HEALTH CARE JOHNSON CREEK Tier 1<br />
400 DOCTORS COURT<br />
02/01/2012<br />
JOHNSON CREEK, WI 53038<br />
01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/14/2008<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 107 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2870<br />
FOSTER CARE YOUTH INDEPENDENCE (FCYI)<br />
CENTER OF WI, INC<br />
JAMES A PEKRUL<br />
2433 N HOLTON STREET<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
FYICenterMKE@aol.com<br />
Phone: (414) 264-6290<br />
Fax: (414) 264-6073<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/2009<br />
07/01/2009<br />
06/30/2010<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2508<br />
FOUNDATIONS COUNSELING CENTER, LLC<br />
ALISA KELLY-MARTINA<br />
619 RIVER STREET<br />
BELLEVILLE, WI 53508<br />
County: Dane<br />
foundations3@frontier.com<br />
Phone: (608) 424-9100<br />
Fax: (608) 424-9099<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2004<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2794<br />
FOX CITIES COMMUNITY HEALTH CENTER<br />
KRISTENE STACKER<br />
1814 N APPLETON ROAD<br />
MENASHA, WI 54952<br />
County: W<strong>in</strong>nebago<br />
kristene.stacker@thedacare.org<br />
Phone: (920) 750-6611<br />
Fax: (920) 882-2946<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2009 06/30/2010<br />
07/01/2009 06/30/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2008<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
EMERGENCY SHELTER OF THE FOX<br />
VALLEY<br />
400 N DIVISION STREET<br />
APPLETON, WI 54911<br />
04/01/2011 03/31/2013<br />
Tier 1<br />
07/01/2011<br />
06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011 06/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 108 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2838<br />
FOX VALLEY CHILDREN'S MENTAL HEALTH<br />
CENTER<br />
GREG VANDENBERG<br />
1820 APPLETON AVENUE<br />
MENASHA, WI 54952<br />
County: W<strong>in</strong>nebago<br />
gv<strong>and</strong>enberg@chw.org<br />
Phone: (920) 996-2200<br />
Fax: (920) 996-2214<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/24/2008<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
2263<br />
FOX VALLEY PSYCHIATRIC ASSOCIATES<br />
MICHAEL PANZER, MD<br />
3301-C NORTH BALLARD ROAD<br />
APPLETON, WI 54911<br />
County: Outagamie<br />
fvpa1@yahoo.com<br />
Phone: (920) 202-3954<br />
Fax: (920) 202-3964<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
CHILD ADVOCACY CENTER Tier 1<br />
325 NORTH COMMERCIAL STREET<br />
11/01/2011<br />
NEENAH, WI 54956<br />
10/31/2013<br />
FOX VALLEY CHILDREN'S MENTAL<br />
HEALTH CTR<br />
Tier 1<br />
545 S JOHN STREET<br />
11/01/2011<br />
KIMBERLY, WI 54136<br />
10/31/2013<br />
FOX VALLEY CHILDREN'S MENTAL<br />
HEALTH CTR<br />
Tier 1<br />
2725 E FOREST STREET<br />
11/01/2011<br />
APPLETON, WI 54915<br />
10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/26/2000<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2076<br />
FROEDTERT HEALTH COMMUNITY MEMORIAL<br />
HOSPITAL<br />
LYNN DUNN<br />
W180 N8085 TOWN HALL ROAD<br />
MENOMONEE FALLS, WI 53051<br />
County: Waukesha<br />
ldunn@froedterthealth.org<br />
Phone: (262) 257-3580<br />
Fax: (262) 257-2570<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1982<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
NO BRANCH LOCATIONS<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2010 08/31/2012<br />
09/01/2010 08/31/2012<br />
09/01/2010 08/31/2012<br />
09/01/2010 08/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 109 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1579<br />
FROEDTERT PHYSICIANS PARTNERS<br />
JULIE MONDROSKI<br />
N91 W17271 APPLETON AVENUE, #1<br />
MENOMONEE FALLS, WI 53051<br />
County: Waukesha<br />
Julie.Mondroski@Froedterthealth.org<br />
Phone: (262) 502-3300<br />
Fax: (262) 532-9598<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/1981<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2811<br />
GAM BEHAVIORAL HEALTH SERVICES, LLC<br />
GLENDA MC CONNELL<br />
3021 HOLMGREN WAY, #203-A<br />
GREEN BAY, WI 54304<br />
County: Brown<br />
gam@um.att.com<br />
Phone: (920) 339-9307<br />
Fax: (920) 339-9374<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
FROEDERT PHYSICIANS PARTNERS Tier 2<br />
W168 N11237 WESTERN AVENUE<br />
10/01/2011<br />
GERMANTOWN, WI 53022<br />
09/30/2013<br />
FROEDERT PHYSICIANS PARTNERS Tier 2<br />
110 LONE OAK LANE<br />
10/01/2011<br />
HARTFORD, WI 53027<br />
09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/29/2008<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2479<br />
GATEWAY TO CHANGE<br />
GLENDA HAMPTON<br />
2319 W. CAPITOL DRIVE<br />
MILWAUKEE, WI 53206<br />
County: Milwaukee<br />
g2ced@sbcglobal.net<br />
Phone: (414) 442-2033<br />
Fax: (414) 442-2167<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2011 09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/29/2003<br />
12/01/2010<br />
11/30/2012<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 110 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1376<br />
GENESIS BEHAVIORAL SERVICES HARTFORD<br />
OUTPATIENT CLINIC<br />
GINA SINGLETERY<br />
1567 E. SUMNER STREET<br />
HARTFORD, WI 53027<br />
County: Wash<strong>in</strong>gton<br />
GS<strong>in</strong>gletery@cmsstl.com<br />
Phone: (414) 777-1570<br />
Fax: (414) 777-1565<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/1994<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2200<br />
GENESIS BEHAVIORAL SERVICES OPTIONS<br />
RESIDENTIAL PROGRAM<br />
GINA SINGLETERY<br />
6755 - 14TH AVENUE<br />
KENOSHA, WI 53140<br />
County: Kenosha<br />
GS<strong>in</strong>gletary@cmsstl.com<br />
Phone: (414) 777-1570<br />
Fax: (414) 777-1565<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/14/2000<br />
04/01/2012<br />
03/31/2014<br />
CSAS-Transitional Residential DHS 75.14<br />
1378<br />
GENESIS BEHAVIORAL SERVICES RACINE<br />
OUTPATIENT CLINIC<br />
GINA SINGLETERY<br />
1654 WASHINGTON AVENUE<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
g<strong>in</strong>a.s<strong>in</strong>gletery@corizonhealth.com<br />
Phone: (414) 633-5001<br />
Fax: (414) 633-2928<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1989<br />
03/01/2012<br />
02/28/2014<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 111 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2777<br />
GENESIS BEHAVIORAL SERVICES, INC. CHATHAM<br />
HOUSE<br />
GINA SINGLETARY<br />
1636 CHATHAM STREET<br />
RACINE, WI 53402<br />
County: Rac<strong>in</strong>e<br />
g<strong>in</strong>a.s<strong>in</strong>gletery@corizonhealth.com<br />
Phone: (262) 637-2679<br />
Fax: (262) 637-2620<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/2008<br />
03/01/2011<br />
02/28/2013<br />
CSAS-Transitional Residential DHS 75.14<br />
1380<br />
GENESIS BEHAVIORAL SERVICES, INC.<br />
CROSSROADS<br />
GINA SINGLETERY<br />
1725 SPRING PLACE<br />
RACINE, WI 53402<br />
County: Rac<strong>in</strong>e<br />
No Email Address Provided<br />
Phone: (414) 777-1570<br />
Fax: (414) 777-1565<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1994<br />
09/01/2010<br />
08/31/2012<br />
CSAS-Transitional Residential DHS 75.14<br />
1383<br />
GENESIS BEHAVIORAL SERVICES, INC. MEN'S<br />
AODA RESIDENTIAL<br />
PAULINE ORTLOFF<br />
2436 N. 50TH STREET<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
g<strong>in</strong>a.s<strong>in</strong>gletery@corizonhealth.com<br />
Phone: (414) 442-5990<br />
Fax: (414) 449-3993<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/15/1992<br />
08/01/2012<br />
07/31/2014<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
09/01/2010 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 07/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 112 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2730<br />
GENESIS BEHAVIORAL SERVICES, INC. SPRING<br />
PLACE<br />
GINA SINGLETERY<br />
4107-09 ST CLAIR STREET<br />
RACINE, WI 53402<br />
County: Rac<strong>in</strong>e<br />
G<strong>in</strong>a.S<strong>in</strong>gletery@corizonhealth.com<br />
Phone: (262) 633-3889<br />
Fax: (262) 633-5626<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/09/2007<br />
05/01/2011<br />
04/30/2013<br />
CSAS-Transitional Residential DHS 75.14<br />
1465<br />
GENESIS BEHAVIORAL SERVICES, INC. WEST<br />
BEND OUTPATIENT CLINIC<br />
GINA SINGLETERY<br />
1626 CLARENCE COURT<br />
WEST BEND, WI 53095<br />
County: Wash<strong>in</strong>gton<br />
G<strong>in</strong>a.s<strong>in</strong>gletery@corizonhealth.com<br />
Phone: (414) 777-1570<br />
Fax: (414) 777-1565<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1987<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
05/01/2011 04/30/2013<br />
GENESIS BEHAVIORAL SERVICES, INC Tier 2<br />
500 N SCHMIDT ROAD<br />
01/01/2012<br />
WEST BEND, WI 53095<br />
12/31/2013<br />
GENESIS BEHAVIORAL SERVICES, INC Tier 2<br />
400 UNIVERSITY DRIVE<br />
01/01/2012<br />
WEST BEND, WI 53095<br />
12/31/2013<br />
GENESIS BEHAVIORAL SERVICES, INC Tier 1<br />
W175 N11163 STONEWOOD DRIVE, #208 01/01/2012<br />
GERMANTOWN, WI 53022<br />
12/31/2013<br />
GENESIS COMP WOMEN'S RECOVERY<br />
PROGRAM<br />
Tier 1<br />
279 S 17TH AVENUE<br />
01/01/2012<br />
WEST BEND, WI 53095<br />
01/01/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 113 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1381<br />
GENESIS COUNSELING SERVICES, LTD.<br />
JAMES BURNS PHD<br />
ONE S. MAIN STREET<br />
JANESVILLE, WI 53545<br />
County: Rock<br />
jburns@gencounsel<strong>in</strong>g.com<br />
Phone: (608) 757-0404<br />
Fax: (608) 757-2319<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1988<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1462<br />
GENESIS DETOXIFICATION CENTER<br />
GINA SINGLETERY<br />
2835 N 32ND STREET<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
g<strong>in</strong>a.s<strong>in</strong>gletery@corizonhealth.com<br />
Phone: (414) 342-6200<br />
Fax: (414) 342-4480<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1988<br />
07/01/2011<br />
06/30/2013<br />
CSAS-Ambulatory Detoxification DHS 75.08<br />
CSAS-Medically Monitored Residential Detox DHS 75.07<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Residential Intoxication Monitor<strong>in</strong>g DHS 75.09<br />
1382<br />
GENESIS HOUSE - LUTHERAN SOCIAL SERVICES<br />
DEBRA ADAMUS<br />
1002 MOTOR AVENUE<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
debra.adamus@lsswis.org<br />
Phone: (262) 544-0711<br />
Fax: (262) 544-1322<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1994<br />
07/01/2012<br />
06/30/2014<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
07/01/2011 04/10/2012<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 114 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1377<br />
GENESIS MILWAUKEE OUTPATIENT CLINIC<br />
GINA SINGLETERY<br />
230 W WELLS STREET, #312<br />
MILWAUKEE, WI 53203<br />
County: Milwaukee<br />
G<strong>in</strong>a.S<strong>in</strong>gletery@Corizon<strong>Health</strong>.com<br />
Phone: (414) 344-3406<br />
Fax: (414) 344-0107<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/1987<br />
12/01/2011<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1379<br />
GENESIS SHEBOYGAN RESIDENTIAL PROGRAM<br />
GINA SINGLETERY<br />
503 E. WISCONSIN AVENUE<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
gs<strong>in</strong>gletery@corizonhealth.com<br />
Phone: (920) 457-7802<br />
Fax: (920) 457-7947<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
GENESIS MILW OUTPATIENT CLINIC<br />
SOUTHSIDE<br />
1673 S 9TH STREET, LOWER LEVEL<br />
MILWAUKEE, WI 53204<br />
Tier 1<br />
06/11/2012<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1991<br />
11/01/2010<br />
10/31/2012<br />
CSAS-Transitional Residential DHS 75.14<br />
2033<br />
GENESIS WOMEN'S RESIDENTIAL PROGRAM<br />
GINA SINGLETERY<br />
5427 W. VILLARD STREET<br />
MILWAUKEE, WI 53218<br />
County: Milwaukee<br />
g<strong>in</strong>a.s<strong>in</strong>gletery@corizonhealth.com<br />
Phone: (414) 777-1570<br />
Fax: (414) 777-1565<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2012<br />
12/01/2011 11/30/2012<br />
12/01/2011 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/15/1998<br />
06/01/2012<br />
05/31/2013<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 115 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2158<br />
GERI CZARNECKI COUNSELING SERVICES<br />
GERMAINE CZARNECKI<br />
1039 W. MASON STREET<br />
GREEN BAY, WI 54303<br />
County: Brown<br />
czarnecki@new.rr.com<br />
Phone: (920) 884-1084<br />
Fax: (920) 496-7922<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/20/1999<br />
12/01/2007<br />
11/30/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2959<br />
GET CONNECTED COUNSELING LLC<br />
CHERIE LINDBERG<br />
5497 WATERFORD LN STE A<br />
APPLETON, WI 54913<br />
County: Outagamie<br />
cheriel@getconnectedcounsel<strong>in</strong>g.com<br />
Phone: (920) 841-2113<br />
Fax: (920) 750-6121<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/05/2012<br />
03/05/2012<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2774<br />
GOODMAN'S BEHAVIORAL HEALTH CLINIC LLC<br />
BARBARA GOODMAN<br />
1104 - 21ST STREET<br />
REEDSBURG, WI 53959<br />
County: Sauk<br />
goodmanbehavioralhealth@yahoo.com<br />
Phone: (608) 768-4545<br />
Fax: (608) 768-4646<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2007 11/30/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/06/2008<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
03/05/2012 02/28/2013<br />
03/05/2012 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 116 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2932<br />
GREAT LAKES MENTAL HEALTH CENTER, LLC<br />
DAMIAN VRANIAK, PHD<br />
15910 W COMPANY LAKE ROAD<br />
HAYWARD, WI 54843<br />
County: Sawyer<br />
No Email Address Provided<br />
Phone: (715) 634-6001<br />
Fax: (715) 634-6001<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/26/2011<br />
01/26/2011<br />
12/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1277<br />
GREAT LAKES RECOVERY CENTER<br />
GREG TOUTANT<br />
427 S. STEPHENSON AVENUE, #214<br />
IRON MOUNTAIN, MI 49801<br />
County/State: Dick<strong>in</strong>son, MI<br />
gtoutant@greatlakesrecovery.org<br />
Phone: (906) 774-2561<br />
Fax: (906) 774-2597<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
GREAT LAKES MENTAL HLTH<br />
CTR-SPRINGBROOK<br />
W3177 HAMILTON ROAD<br />
SPRINGBROOK, WI 54875<br />
Tier 1<br />
02/01/2011<br />
12/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/09/2011<br />
11/09/2011<br />
10/31/2012<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2967<br />
GREEN BAY COUNSELING, INC.<br />
CAROL J. BURKS<br />
2301 RIVERSIDE DRIVE, #8<br />
GREEN BAY, WI 54301<br />
County: Brown<br />
gbcounsel<strong>in</strong>g1@gmail.com<br />
Phone: (920) 217-7547<br />
Fax: No Number Provided<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/26/2011 12/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012<br />
06/01/2012<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
11/09/2011 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 117 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1387<br />
GREEN BAY WELLNESS & BEHAVIORAL HEALTH<br />
CLINIC<br />
MICHAEL MERVILDE<br />
125 S. JEFFERSON STREET, #306<br />
GREEN BAY, WI 54301<br />
County: Brown<br />
mmervilde@aol.com<br />
Phone: (920) 437-7878<br />
Fax: (920) 437-5884<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1985<br />
07/01/2010<br />
06/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2328<br />
GREEN COUNTY HUMAN SERVICES COMMUNITY<br />
SUPPORT PROGRAM<br />
GREG HOLCOMB<br />
N 3152 STATE ROAD 81<br />
MONROE, WI 53566<br />
County: Green<br />
gholcomb@gchsd.org<br />
Phone: (608) 328-9399<br />
Fax: (608) 328-9480<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2000<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2842<br />
GREEN COUNTY HUMAN SERVICES<br />
COMPREHENSIVE COMMUNITY SERVICES<br />
GREG HOLCOMB<br />
N3152 STATE ROAD 81<br />
MONROE, WI 53566<br />
County: Green<br />
gholcomb@gchsd.org<br />
Phone: (508) 328-9399<br />
Fax: (608) 328-9480<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2010 06/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/22/2009<br />
01/01/2012<br />
12/31/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 118 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1388<br />
GREEN COUNTY HUMAN SERVICES<br />
GREG HOLCOMB<br />
N3152 STATE ROAD 81<br />
MONROE, WI 53566<br />
County: Green<br />
gholcomb@gchsd.org<br />
Phone: (608) 328-9399<br />
Fax: (608) 328-9480<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1975<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2265<br />
GREEN LAKE COUNTY DEPARTMENT OF HEALTH<br />
& HUMAN SERVICES CSP<br />
LINDA RICHARDS<br />
571 COUNTY ROAD A<br />
GREEN LAKE, WI 54941<br />
County: Green Lake<br />
glcdhhs@co.green-lake.wi.us<br />
Phone: (920) 294-4070<br />
Fax: (920) 294-4139<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2000<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2010 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 119 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1389<br />
GREEN LAKE COUNTY DEPARTMENT OF HEALTH<br />
& HUMAN SERVICES<br />
LINDA VAN NESS<br />
571 COUNTY ROAD A<br />
GREEN LAKE, WI 54941<br />
County: Green Lake<br />
glcdhhs@co.green-lake.wi.us<br />
Phone: (920) 294-4070<br />
Fax: (920) 294-4139<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/1977<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2599<br />
GREEN LAKE COUNTY DHHS COMPREHENSIVE<br />
COMMUNITY SERVICES<br />
LINDA RICHARDS<br />
571 COUNTY ROAD A<br />
GREEN LAKE, WI 54941<br />
County: Green Lake<br />
glcdhhs@co.green-lake.wi.us<br />
Phone: (920) 294-4070<br />
Fax: (920) 294-4139<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
BERLIN HIGH SCHOOL Tier 1<br />
222 MEMORIAL DRIVE<br />
11/01/2010<br />
BERLIN, WI 54923<br />
10/31/2012<br />
BERLIN MIDDLE SCHOOL Tier 1<br />
289 E HURON STREET<br />
11/01/2010<br />
BERLIN, WI 54923<br />
10/31/2012<br />
WASHINGTON ALTERNATIVE SCHOOL Tier 1<br />
344 BROADWAY STREET<br />
11/01/2011<br />
BERLIN, WI 54923<br />
10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/22/2005<br />
09/01/2011<br />
08/31/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
2747<br />
GREENSQUARE DEVELOPMENTAL SPECIALISTS<br />
TRACY CLEMENS<br />
6791 N GREEN BAY AVENUE<br />
GLENDALE, WI 53209<br />
County: Milwaukee<br />
tclemens@chw.org<br />
Phone: (414) 228-4800<br />
Fax: (414) 247-0894<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/17/2007<br />
08/01/2012<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
GREENSQUARE DEVELOPMENTAL<br />
SPECIALISTS<br />
7300 SOUTH 13TH STREET<br />
OAK CREEK, WI 53154<br />
09/01/2011 08/31/2013<br />
Tier 2<br />
08/01/2012<br />
08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 08/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 120 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2883<br />
GREENTREE COUNSELING LLC<br />
BARB HEDGES-GOETTL<br />
166 E GENEVA SQUARE<br />
LAKE GENEVA, WI 53147<br />
County: Walworth<br />
greentreecounsel<strong>in</strong>g@gmail.com<br />
Phone: (262) 249-0830<br />
Fax: (262) 249-0835<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/07/2009<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2803<br />
GRO FAMILY SERVICES<br />
GREGORY OWENS<br />
2011 W CAPITOL DRIVE<br />
MILWAUKEE, WI 53206<br />
County: Milwaukee<br />
acc_gro@yahoo.com<br />
Phone: (414) 445-1400<br />
Fax: (414) 395-4716<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/28/2008<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2101<br />
GUEST HOUSE COUNSELING CLINIC<br />
ANDREW MUSGRAVE<br />
1216 N. 13TH STREET<br />
MILWAUKEE, WI 53205<br />
County: Milwaukee<br />
<strong>and</strong>rew.musgrave@guesthouseofmilwaukee.org<br />
Phone: (414) 345-3240<br />
Fax: (414) 345-3258<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/15/1992<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 121 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1391<br />
GUNDERSEN CLINIC LIMITED, BEHAVIORAL<br />
HEALTH<br />
ANN STEKEL<br />
1836 SOUTH AVENUE<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
amstekel@gundluth.org<br />
Phone: (608) 782-7300<br />
Fax: (608) 775-4410<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/1984<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
GUNDERSEN CLINIC Tier 2<br />
123 - 16TH AVENUE SOUTH<br />
12/01/2010<br />
ONALASKA, WI 54650<br />
11/30/2012<br />
GUNDERSEN CLINIC Tier 2<br />
1830 STATE HWY 9<br />
12/01/2010<br />
DECORAH, IA 52101<br />
11/30/2012<br />
GUNDERSEN CLINIC Tier 1<br />
505 CENTER STREET<br />
12/01/2010<br />
WONEWOC, WI 53968<br />
07/01/2011<br />
GUNDERSEN CLINIC LTD, BEHAV HLTH Tier 2<br />
18606 ERVIN STREET<br />
12/01/2010<br />
WHITEHALL, WI 54773<br />
11/30/2012<br />
GUNDERSEN CLINIC, LTD-LA CRESCENT Tier 1<br />
226 NORTH 2ND STREET<br />
12/01/2010<br />
LA CRESCENT, MN 55947<br />
11/30/2012<br />
GUNDERSEN CLINIC-SPARTA Tier 2<br />
218 W MAIN STREET<br />
12/01/2010<br />
SPARTA, WI 54656<br />
11/30/2012<br />
GUNDERSEN LUTHERAN MED<br />
CTR-BEHAV HLTH<br />
Tier 2<br />
3111 GUNDERSEN DRIVE<br />
12/01/2010<br />
ONALASKA, WI 54650<br />
11/30/2012<br />
GUNDERSEN-PRAIRIE DU CHIEN CLINIC Tier 2<br />
610 E TAYLOR STREET<br />
12/01/2010<br />
PRAIRIE DU CHIEN, WI 53821<br />
11/30/2012<br />
GUNDERSON CLINIC LTD Tier 1<br />
420 SOUTH PETERSON AVENUE<br />
04/14/2011<br />
BLAIR, WI 54616<br />
11/30/2012<br />
GUNDERSON CLINIC LTD Tier 1<br />
35791 OSSEO ROAD<br />
04/14/2011<br />
INDEPENDENCE, WI 54747<br />
11/30/2012<br />
RIVER PARK SUITES Tier 2<br />
601 N SUPERIOR<br />
12/01/2010<br />
TOMAH, WI 54660<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 122 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1520<br />
GUNDERSEN LUTHERAN MEDICAL CENTER, INC.<br />
BEHAVIORAL HEALTH<br />
ANN STEKEL<br />
1910 SOUTH AVENUE<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
amstekel@gundluth.org<br />
Phone: (608) 782-7300<br />
Fax: (608) 775-4410<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1982<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
1951<br />
GUNDERSEN LUTHERAN MEDICAL CENTER, INC.,<br />
UNITY HOUSE FOR MEN<br />
ANN STEKEL<br />
1922-1924 MILLER STREET<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
amstekel@gundluth.org<br />
Phone: (608) 775-4753<br />
Fax: (608) 775-4791<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
GUNDERSEN LUTH MED CTR BEHAV<br />
HEALTH<br />
610 E TAYLOR STREET<br />
PRAIRIE DU CHIEN, WI 53821<br />
GUNDERSEN LUTH MED CTR BEHAV<br />
HEALTH<br />
218 W MAIN STREET<br />
SPARTA, WI 54656<br />
GUNDERSEN LUTH MED CTR BEHAV<br />
HEALTH<br />
18606 ERVIN STREET<br />
WHITEHALL, WI 54773<br />
GUNDERSEN LUTH MED CTR BEHAV<br />
HEALTH<br />
123 - 16TH AVENUE SOUTH<br />
ONALASKA, WI 54650<br />
GUNDERSEN LUTH MED CTR BEHAV<br />
HEALTH<br />
601 N SUPERIOR AVENUE<br />
TOMAH, WI 54660<br />
GUNDERSEN LUTH MED CTR BEHAV<br />
HEALTH<br />
3111 GUNDERSEN DRIVE<br />
ONALASKA, WI 54650<br />
Tier 2<br />
12/01/2010<br />
11/30/2012<br />
Tier 2<br />
12/01/2010<br />
11/30/2012<br />
Tier 2<br />
12/01/2010<br />
11/30/2012<br />
Tier 2<br />
12/01/2010<br />
11/30/2012<br />
Tier 2<br />
12/01/2010<br />
11/30/2012<br />
Tier 2<br />
12/01/2010<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1993<br />
12/01/2010<br />
11/30/2012<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
10/12/2011 11/30/2012<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
10/12/2011 11/30/2012<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 123 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2782<br />
GUNDERSEN LUTHERAN MEDICAL CENTER, INC.,<br />
UNITY HOUSE FOR MEN<br />
ANN STEKEL<br />
1918-1920 MILLER STREET<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
amstekel@gundluth.org<br />
Phone: (608) 775-4753<br />
Fax: (608) 775-4791<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/2008<br />
12/01/2010<br />
11/30/2012<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
2280<br />
GUNDERSEN LUTHERAN MEDICAL CENTER, INC.,<br />
BEHAVIORAL HEALTH<br />
ANN STEKEL<br />
123 - 16TH AVENUE, SOUTH<br />
ONALASKA, WI 54650<br />
County: La Crosse<br />
amstekel@gundluth.org<br />
Phone: (608) 782-7300<br />
Fax: (608) 775-4410<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2000<br />
12/01/2010<br />
11/30/2012<br />
CSAS-Day Treatment DHS 75.12<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
1952<br />
GUNDERSEN LUTHERAN MEDICAL CENTER, INC.,<br />
UNITY HOUSE FOR WOMEN<br />
ANN STEKEL<br />
1312 FIFTH AVENUE, SOUTH<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
amstekel@gundluth.org<br />
Phone: (608) 775-4718<br />
Fax: (608) 775-4710<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1993<br />
12/01/2010<br />
11/30/2012<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 124 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2024<br />
HARAMBEE OMBUDSMAN - IMANI II<br />
REGINALD PEOPLES<br />
3614 N. 39TH STREET<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
rtpeoples@yahoo.com<br />
Phone: (414) 442-6334<br />
Fax: (414) 442-6362<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/28/1996<br />
12/01/2009<br />
11/30/2011<br />
CSAS-Transitional Residential DHS 75.14<br />
2044<br />
HARBOR NORTH COUNSELING<br />
TIMOTHY FAUST<br />
14 E. BAYFIELD STREET<br />
WASHBURN, WI 54891<br />
County: Bayfield<br />
No Email Address Provided<br />
Phone: (715) 373-0480<br />
Fax: (715) 373-0480<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1998<br />
09/01/2010<br />
01/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1399<br />
HAZELDEN CENTER FOR YOUTH & FAMILIES<br />
MICHAEL ERB<br />
11505 - 36TH AVENUE, NORTH<br />
PLYMOUTH, MN 55441<br />
County/State: Hennep<strong>in</strong>, MN<br />
merb@hazelden.org<br />
Phone: (651) 213-4217<br />
Fax: (651) 213-4344<br />
Surveyor: Polly Wong<br />
Services<br />
12/01/2009 11/30/2011<br />
HARBOR NORTH COUNSELING Tier 1<br />
33RD N 1ST STREET, #100-5<br />
09/01/2010<br />
BAYFIELD, WI 54814<br />
01/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1990<br />
05/01/2011<br />
04/30/2013<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
09/01/2010 01/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 125 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2749<br />
HAZELDEN MENTAL HEALTH CENTER - CENTER<br />
CITY<br />
MICHAEL ERB<br />
15245 PLEASANT VALLEY ROAD<br />
CENTER CITY, MN 55012<br />
County/State: Chisago, MN<br />
merb@hazelden.org<br />
Phone: (651) 213-4217<br />
Fax: (651) 213-4344<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/2007<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2337<br />
HAZELDEN MENTAL HEALTH CENTERS<br />
PLYMOUTH<br />
MIKE ERB<br />
11505 - 36TH AVENUE, NORTH<br />
PLYMOUTH, MN 55441<br />
County/State: Hennep<strong>in</strong>, MN<br />
merb@hazelden.org<br />
Phone: (651) 213-4217<br />
Fax: (651) 213-4344<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/05/2001<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2333<br />
HAZELDEN MENTAL HEALTH CENTERS ST. PAUL<br />
MIKE ERB<br />
680 STEWART AVENUE<br />
SAINT PAUL, MN 55102<br />
County/State: Ramsey, MN<br />
merb@hazelden.org<br />
Phone: (651) 231-4217<br />
Fax: (651) 213-4738<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/19/2002<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 126 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1398<br />
HAZELDEN<br />
MICHAEL ERB<br />
15245 PLEASANT VALLEY ROAD<br />
CENTER CITY, MN 55012<br />
County/State: Chisago, MN<br />
merb@hazelden.org<br />
Phone: (651) 213-4217<br />
Fax: (651) 213-4344<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/1988<br />
05/01/2011<br />
04/30/2013<br />
CSAS-Medically Monitored Residential Detox DHS 75.07<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
2916<br />
HEALING HEARTS FAMILY COUNSELING CENTER,<br />
LLC<br />
PAT ANN ST. GERMAIN<br />
1268 W MAIN STREET, #2<br />
SUN PRAIRIE, WI 53590<br />
County: Dane<br />
patann@heal<strong>in</strong>gheartscares.com<br />
Phone: (608) 333-5945<br />
Fax: (608) 834-1132<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/20/2010<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1777<br />
HEALTH CARE FOR THE HOMELESS OF<br />
MILWAUKEE, INC. CSP<br />
LIZ GABRIEL<br />
711 W. CAPITOL DRIVE, #205<br />
MILWAUKEE, WI 53206<br />
County: Milwaukee<br />
lizg@orchc-milw.org<br />
Phone: (414) 374-2400<br />
Fax: (414) 374-7917<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/17/1996<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
10/01/2011 09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011 06/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 127 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1402<br />
HEALTH PSYCHOLOGY ASSOCIATES, SC<br />
GERALDINE BANKS<br />
5800 N BAYSHORE DR #B230<br />
GLENDALE, WI 53217<br />
County: Milwaukee<br />
hpsych1@yahoo.com<br />
Phone: (414) 962-4072<br />
Fax: (414) 962-4052<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/1991<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2911<br />
HEALTHY CONNECTIONS, LLC<br />
JESSICA SCHROEDER<br />
821 E FIRST AVENUE STE 3<br />
APPLETON, WI 54911<br />
County: Outagamie<br />
healthyconnectionsllc@gmail.com<br />
Phone: (920) 257-4601<br />
Fax: (920) 257-4603<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
HEALTH PSYCHOLOGY ASSOCIATES Tier 2<br />
5007 S HOWELL, #350<br />
05/01/2011<br />
MILWAUKEE, WI 53207<br />
04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/17/2010<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2638<br />
HEARTHSTONE THERAPY & CONSULTING, LLC<br />
DAWN KRUEGER<br />
4810 S 76TH STREET SUITE 106<br />
GREENFIELD, WI 53220<br />
County: Milwaukee<br />
hearthstone2005@sbcglobal.net<br />
Phone: (414) 282-8353<br />
Fax: (414) 282-8353<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/05/2006<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
06/01/2011 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2011 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 128 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1406<br />
HEARTLAND CLINIC<br />
YVONNE ZUBATY<br />
406 ELM STREET<br />
BOSCOBEL, WI 53805<br />
County: Grant<br />
heartl<strong>and</strong>cl<strong>in</strong>ic@mhtc.net<br />
Phone: (608) 375-2700<br />
Fax: (608) 375-2146<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/1989<br />
12/01/2007<br />
11/30/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2669<br />
HERGERT & ASSOCIATES FAMILY COUNSELING<br />
SERVICES<br />
LISA HERGERT<br />
252 S CENTRAL AVENUE, #21<br />
MARSHFIELD, WI 54449<br />
County: Wood<br />
lrherge@aol.com<br />
Phone: (715) 384-7579<br />
Fax: (715) 384-8131<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/08/2006<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1409<br />
HESS MEMORIAL HOSPITAL, INC., DBA MILE<br />
BLUFF MEDICAL CENTER<br />
JIM O'KEEFE<br />
1050 DIVISION STREET<br />
MAUSTON, WI 53948<br />
County: Juneau<br />
mfry@milebluff.com<br />
Phone: (608) 847-6161<br />
Fax: (608) 847-1843<br />
Surveyor: William Rohner<br />
Services<br />
HERGERT & ASSOCIATES FAMILY<br />
COUNSELING<br />
2900 HOOVER AVENUE, #B<br />
STEVENS POINT, WI 54481<br />
12/01/2007 11/30/2009<br />
Tier 1<br />
01/01/2011<br />
12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1987<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
ELROY FAMILY MEDICAL CENTER Tier 1<br />
1515 ACADEMY<br />
05/01/2011<br />
ELROY, WI 53929<br />
04/30/2013<br />
LAKE DELTON CLINIC Tier 1<br />
28 COMMERCE STREET<br />
05/01/2011<br />
LAKE DELTON, WI 53940<br />
04/30/2013<br />
NECEDAH FAMILY MEDICAL CENTER Tier 1<br />
1408 WHEELIHAN AVE<br />
05/01/2011<br />
NECEDAH, WI 54646<br />
04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 129 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2823<br />
HIAWATHA VALLEY MENTAL HEALTH CENTER<br />
JULIE HANSON<br />
166 MAIN STREET<br />
WINONA, MN 55987<br />
County/State: W<strong>in</strong>ona, MN<br />
julieh@hvmhc.org<br />
Phone: (507) 454-4341<br />
Fax: (507) 453-6267<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/21/2009<br />
09/01/2012<br />
08/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2937<br />
HIAWATHA VALLEY MENTAL HEALTH CENTER<br />
JULIE HANSON<br />
319 MAIN STREET<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
julieh@hvmhc.org<br />
Phone: (608) 796-1168<br />
Fax: (608) 796-1944<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
HIAWATHA VALLEY MENTAL HEALTH<br />
CENTER<br />
319 MAIN STREET<br />
LA CROSSE, WI 54601<br />
HIAWATHA VALLEY MENTAL HEALTH<br />
CENTER<br />
LA CROSSE CNTY JUVE FAC.- 300 4TH ST N<br />
LA CROSSE, WI 54601<br />
HIAWATHA VALLEY MENTAL HEALTH<br />
CENTER<br />
611 BROADWAY AVENUE, #100<br />
WABASHA, MN 55981<br />
Tier 2<br />
09/01/2012<br />
08/31/2014<br />
Tier 2<br />
09/01/2012<br />
08/31/2014<br />
Tier 2<br />
09/01/2012<br />
08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2011<br />
03/01/2012<br />
02/28/2013<br />
CSAS-Intervention DHS 75.16<br />
CSAS-Prevention DHS 75.04<br />
2565<br />
HIDDEN SPRINGS CLINIC<br />
DEAN JENSEN<br />
S 1597 HANSON ROAD<br />
WESTBY, WI 54667<br />
County: Vernon<br />
hscdeanj@yahoo.com<br />
Phone: (608) 574-0582<br />
Fax: (608) 634-6918<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/09/2004<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2013<br />
03/01/2012 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 130 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1413<br />
HO-CHUNK NATION DEPARTMENT OF HEALTH<br />
DIVISION OF BEHAVIORAL HEALTH<br />
JULIE ABBOTT-JONES<br />
N6250 LUMBERJACK GUY ROAD<br />
BLACK RIVER FALLS, WI 54615<br />
County: Jackson<br />
julie.abott-jones@ho-chunk.com<br />
Phone: (715) 284-9851<br />
Fax: (715) 284-3434<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/1992<br />
11/01/2011<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2520<br />
HOLISTIC WELLNESS CENTER, LLC<br />
JEFF S. HOLLOWELL PHD<br />
675 N. BROOKFIELD ROAD, #101<br />
BROOKFIELD, WI 53045<br />
County: Waukesha<br />
holisticwellness@att.net<br />
Phone: (262) 641-9300<br />
Fax: (262) 641-9307<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NEKOOSA HEALTH OFFICE Tier 2<br />
916 CHAK-HAH-CHEE LANE<br />
11/01/2011<br />
NEKOOSA, WI 54457<br />
10/31/2012<br />
THREE RIVERS HOUSE Tier 2<br />
724 MAIN STREET<br />
11/01/2011<br />
LA CROSSE, WI 54601<br />
10/31/2012<br />
TOMAH HEALTH OFFICE Tier 2<br />
27374 HWY 21 EAST<br />
11/01/2011<br />
TOMAH, WI 54660<br />
10/31/2012<br />
WELLNESS CENTER HEALTH OFFICE Tier 2<br />
S2845 WHITE EAGLE ROAD<br />
11/01/2011<br />
BARABOO, WI 53913<br />
10/31/2012<br />
WITTENBERG HEALTH OFFICE Tier 2<br />
N7240 HWY 49 NORTH<br />
11/01/2011<br />
WITTENBERG, WI 54499<br />
10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/18/2004<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2012<br />
11/01/2011 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2011 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 131 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1416<br />
HOLY FAMILY MEMORIAL MEDICAL CENTER<br />
NEIL MURPHY<br />
2300 WESTERN AVENUE<br />
MANITOWOC, WI 54221<br />
County: Manitowoc<br />
No Email Address Provided<br />
Phone: (920) 320-2499<br />
Fax: No Number Provided<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/1985<br />
03/01/2008<br />
02/28/2010<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
1024<br />
HOPE COUNCIL ON ALCOHOL & OTHER DRUG<br />
ABUSE, INC.<br />
GUIDA BROWN<br />
5942 - SIXTH AVENUE<br />
KENOSHA, WI 53140<br />
County: Kenosha<br />
<strong>in</strong>fo@hopecouncil.org<br />
Phone: (262) 658-8166<br />
Fax: (262) 658-8210<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/15/1990<br />
03/01/2011<br />
02/28/2013<br />
CSAS-Intervention DHS 75.16<br />
1418<br />
HOPE HAVEN, INC.<br />
JAMES CRAWFORD<br />
425 W. JOHNSON STREET<br />
MADISON, WI 53703<br />
County: Dane<br />
hopehaven_james@yahoo.com<br />
Phone: (608) 251-8881<br />
Fax: (608) 251-2926<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2008 02/28/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1982<br />
12/01/2011<br />
11/30/2013<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011 11/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 132 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1774<br />
HOPE HAVEN/REBOS UNITED, INC. - CHRIS<br />
FARLEY HOUSE<br />
BRUCE NICHOLAS<br />
810 W. OLIN AVENUE<br />
MADISON, WI 53715<br />
County: Dane<br />
b.nicholashh@gmail.com<br />
Phone: (608) 255-5922<br />
Fax: (608) 255-0340<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1993<br />
12/01/2010<br />
11/30/2012<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Transitional Residential DHS 75.14<br />
2366<br />
HOWARD JANSEN DAY TREATMENT 2<br />
LISA SCHON<br />
5151 W SILVER SPRING DRIVE<br />
MILWAUKEE, WI 53218<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 527-6970<br />
Fax: (414) 527-6971<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/03/2002<br />
04/01/2010<br />
03/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 2 DHS 40.11(2)(b)<br />
1421<br />
HOWARD JANSEN MENTAL HEALTH DAY<br />
TREATMENT PROGRAM<br />
LISA SHON<br />
3903 W. LISBON AVENUE<br />
MILWAUKEE, WI 53208<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 342-2060<br />
Fax: (414) 342-3663<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/24/1997<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 2 DHS 40.11(2)(b)<br />
NO BRANCH LOCATIONS<br />
04/01/2010 03/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2011 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 133 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1173<br />
HUDSON HOSPITAL, PROGRAMS FOR CHANGE<br />
PETER VAN DUSARTZ<br />
901 DOMINION DRIVE<br />
HUDSON, WI 54016<br />
County: Sa<strong>in</strong>t Croix<br />
Peter.J.V<strong>and</strong>usartz@HudsonHospital.org<br />
Phone: (715) 531-6752<br />
Fax: (715) 531-6766<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1990<br />
12/01/2011<br />
11/30/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2312<br />
HUMAN DEVELOPMENT CENTER MENTAL<br />
HEALTH CENTER COMMUNITY SUPPORT<br />
PROGRAM<br />
STEVE ENGLESON<br />
1500 N 34TH STREET, #200<br />
SUPERIOR, WI 54880<br />
County: Douglas<br />
steve.engleson@hdchrc.org<br />
Phone: (715) 392-8216<br />
Fax: (715) 392-6055<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1982<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1423<br />
HUMAN DEVELOPMENT CENTER MENTAL<br />
HEALTH CENTER<br />
BETSY BYLER<br />
1500 N 34TH STREET, #200<br />
SUPERIOR, WI 54880<br />
County: Douglas<br />
betsy.byler@hdchrc.org<br />
Phone: (715) 392-8216<br />
Fax: (715) 392-6055<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1982<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 2 DHS 34.2<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 134 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1427<br />
HUMAN SERVICE CENTER - NORTHWOODS<br />
GUIDANCE CENTER<br />
DONNA SCHIMECK<br />
705 EAST TIMBER DRIVE<br />
RHINELANDER, WI 54501<br />
County: Oneida<br />
ds@thehumanservicecenter.org<br />
Phone: (715) 369-2215<br />
Fax: (715) 369-2214<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1980<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 w/Telehealth DHS 34.3<br />
2827<br />
HUMAN SERVICE CTR - NORTHWOODS GUIDANCE<br />
CTR TRI-CO COMPREHENSIVE COMM SVS<br />
DONNA SHIMECK<br />
705 E TIMBER DRIVE<br />
RHINELANDER, WI 54501<br />
County: Oneida<br />
ds@thehumanservicecenter.org<br />
Phone: (715) 369-2215<br />
Fax: (715) 369-2214<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
HUMAN SERVICE CTR-NORTHWOODS<br />
GUIDANCE<br />
1991 WINNEBAGO STREET<br />
RHINELANDER, WI 54501<br />
Tier 1<br />
10/01/2011<br />
09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2009<br />
06/01/2011<br />
05/31/2013<br />
Comprehensive Community Services with Telehealth DHS 36<br />
Comprehensive Community Services (CCS) DHS 36<br />
1429<br />
ICF CONSULTANTS, INC.<br />
MARILYN BONJEAN<br />
1524 N. FARWELL AVENUE<br />
MILWAUKEE, WI 53202<br />
County: Milwaukee<br />
icfconsultants.com<br />
Phone: (414) 273-2220<br />
Fax: (414) 273-2223<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1988<br />
11/01/2009<br />
10/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
06/01/2011 05/31/2013<br />
06/01/2011 05/31/2013<br />
ICF CONSULTANTS INC Tier 1<br />
700 PILGRIM PARKWAY<br />
11/01/2009<br />
ELM GROVE, WI 53122<br />
10/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2009 10/31/2011
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 135 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2164<br />
IMPACT COUNSELING SERVICES, LLC<br />
RENEE MILLWOOD<br />
15655 CO HWY B<br />
HAYWARD, WI 54843<br />
County: Sawyer<br />
icscl<strong>in</strong>ics@icscl<strong>in</strong>ics.org<br />
Phone: (715) 634-0607<br />
Fax: (715) 634-0617<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1999<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2292<br />
IMPACT COUNSELING SERVICES, LLC<br />
RENEE MIILLWOOD<br />
158 S ANDERSON STREET<br />
RHINELANDER, WI 54501<br />
County: Oneida<br />
icscl<strong>in</strong>ics@icscl<strong>in</strong>ics.org<br />
Phone: (715) 362-6390<br />
Fax: (715) 362-6391<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
IMPACT COUNSELING SERVICES LLC Tier 1<br />
306 STATE HWY 70 EAST<br />
08/01/2012<br />
SAINT GERMAIN, WI 54558<br />
10/31/2013<br />
IMPACT COUNSELING SERVICES LLC Tier 2<br />
17A WEST DAVENPORT<br />
08/01/2012<br />
RHINELANDER, WI 54501<br />
10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/09/2001<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2612<br />
IMPACT COUNSELING SERVICES, LLC<br />
RENEE MILLWOOD<br />
301 S ELLIS AVENUE<br />
ASHLAND, WI 54806<br />
County: Ashl<strong>and</strong><br />
icscl<strong>in</strong>ics@icscl<strong>in</strong>ics.org<br />
Phone: (715) 682-3523<br />
Fax: (715) 682-3526<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2005<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
NO BRANCH LOCATIONS<br />
09/01/2010 08/31/2012<br />
09/01/2010 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2010 08/31/2012<br />
09/01/2010 08/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 136 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2746<br />
IMPACT, ALCOHOL AND OTHER DRUG ABUSE<br />
SERVICE, INC<br />
PATRICIA GUTIERREZ<br />
6737 W WASHINGTON STREET, #2225<br />
WEST ALLIS, WI 53214<br />
County: Milwaukee<br />
pgutierrez@impact<strong>in</strong>c.org<br />
Phone: (414) 256-4808<br />
Fax: (414) 771-4808<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/09/2007<br />
08/01/2012<br />
07/31/2014<br />
CSAS-Intervention DHS 75.16<br />
2313<br />
INDEPENDENT ASSESSMENT & COUNSELING<br />
SERVICES<br />
KENNETH SANN<br />
1345 W MASON STREET, #200<br />
GREEN BAY, WI 54303<br />
County: Brown<br />
Ks.iacs@tds.net<br />
Phone: (920) 438-8141<br />
Fax: (920) 438-7993<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
IMPACT, ALCOHOL & OTHER DRUG<br />
ABUSE SERVICE<br />
2266 PROSPECT AVENUE, #324<br />
MILWAUKEE, WI 53202<br />
Tier 1<br />
08/01/2012<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/22/2001<br />
07/01/2012<br />
06/30/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2296<br />
INNER AWAKENINGS DIAGNOSTIC AND<br />
COUNSELING CLINIC<br />
MELISSA FORD<br />
436 OAKTON AVENUE<br />
PEWAUKEE, WI 53072<br />
County: Waukesha<br />
melissaford@<strong>in</strong>ner-awaken<strong>in</strong>gs.com<br />
Phone: (262) 691-2581<br />
Fax: (262) 691-2761<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/09/2001<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2011 03/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 137 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2388<br />
INNER RESOURCE COUNSELING<br />
KATHRYN WEEKS, MSW, LCSW<br />
4103 - 60TH STREET<br />
KENOSHA, WI 53144<br />
County: Kenosha<br />
weekskathy@hotmail.com<br />
Phone: (262) 652-3000<br />
Fax: (847) 395-6989<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/09/2002<br />
08/01/2009<br />
07/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1434<br />
INNER RESOURCES, INC.<br />
LAURA L. PAULY<br />
12660 W NORTH AVENUE<br />
BROOKFIELD, WI 53005<br />
County: Waukesha<br />
No Email Address Provided<br />
Phone: (262) 789-7100<br />
Fax: No Number Provided<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1994<br />
10/08/2008<br />
05/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1436<br />
INNERVISIONS COUNSELING AND CONSULTING<br />
CENTER, SC<br />
COLLEEN S. JAMES<br />
708 ELIZABETH STREET<br />
BARABOO, WI 53913<br />
County: Sauk<br />
<strong>in</strong>nervisions@centuryl<strong>in</strong>k.net<br />
Phone: (608) 477-9858<br />
Fax: (877) 560-0578<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2009 07/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/19/2007<br />
11/01/2011<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
INNERVISIONS COUNSELING &<br />
CONSULTING CENTER<br />
231 EAST STATE ST<br />
MAUSTON, WI 53948<br />
10/08/2008 05/31/2010<br />
Tier 1<br />
05/01/2012<br />
10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 138 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2283<br />
INNOVATIVE COUNSELING, INC.<br />
CYNTHIA THOMAS<br />
1499 SIXTH STREET<br />
GREEN BAY, WI 54304<br />
County: Brown<br />
angiegurlik@<strong>in</strong>novativecounsel<strong>in</strong>g<br />
Phone: (920) 497-6161<br />
Fax: (920) 498-0476<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/14/2000<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2961<br />
INNOVATIVE RECOVERY<br />
ANGELA RIVERA<br />
1314 WEST NATIONAL AVE<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
arivera@irnw.net<br />
Phone: (414) 383-4432<br />
Fax: (414) 383-4482<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2012<br />
03/01/2012<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1437<br />
INSTITUTE FOR MENTAL HEALTH, S.C.<br />
DORALYNNE METZ PHD<br />
9401 W BELOIT ROAD, #315<br />
MILWAUKEE, WI 53227<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (262) 821-6060<br />
Fax: (262) 821-6077<br />
Surveyor: Mark Isaacs<br />
Services<br />
01/01/2011 12/31/2012<br />
INNOVATIVE RECOVERY Tier 1<br />
5455 SHERIDAN RD SUITE LL-1<br />
06/28/2012<br />
KENOSHA, WI 53140<br />
02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1995<br />
10/26/2007<br />
09/30/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2013<br />
03/01/2012 02/28/2013<br />
03/01/2012 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/26/2007 09/30/2009
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 139 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2628<br />
INTEGRATED COUNSELING CENTER, LLC<br />
ROSONNA S COMERS<br />
N6687 WRIGHTWAY DRIVE #D<br />
FOND DU LAC, WI 54937<br />
County: Fond Du Lac<br />
<strong>in</strong>tegratedcounsel<strong>in</strong>gcenter@yahoo.com<br />
Phone: (920) 929-9140<br />
Fax: (920) 929-9142<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/14/2005<br />
01/01/2010<br />
12/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2843<br />
INTEGRATED COUNSELING CENTER, LLC<br />
ROSONNA S COMMERS<br />
404 N MAIN STREET #612<br />
OSHKOSH, WI 54901<br />
County: W<strong>in</strong>nebago<br />
iccllc@sbcglobal.net<br />
Phone: (920) 651-9264<br />
Fax: (920) 651-9265<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/22/2009<br />
05/22/2009<br />
06/30/2010<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2392<br />
INTEGRATED DEVELOPMENT SERVICES, INC.<br />
SAM GARLOCK<br />
6506 SCHROEDER ROAD<br />
MADISON, WI 53711<br />
County: Dane<br />
sgarlock@ids-wi.com<br />
Phone: (608) 441-0123<br />
Fax: (608) 441-0126<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/01/2010 12/31/2011<br />
01/01/2010 12/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2002<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
06/01/2009 06/30/2010<br />
05/22/2009 06/30/2010<br />
05/22/2009 05/31/2009<br />
INTEGRATED DEVELOPMENT SERVICES Tier 2<br />
762 LOIS DRIVE<br />
09/01/2011<br />
SUN PRAIRIE, WI 53590<br />
08/31/2012<br />
INTEGRATED DEVELOPMENT SERVICES Tier 2<br />
815 FORWARD DRIVE<br />
06/27/2012<br />
MADISON, WI 53711<br />
08/31/2012<br />
INTEGRATED DEVELOPMENT SERVICES Tier 2<br />
2525 N MAYFAIR RD<br />
06/27/2012<br />
WAUWATOSA, WI 53226<br />
08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2010 08/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 140 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1440<br />
INTERCONNECTIONS, S.C.<br />
DEBORAH BISSLAND<br />
920 - 60TH STREET<br />
KENOSHA, WI 53140<br />
County: Kenosha<br />
jbr<strong>and</strong>04@wi.rr.com<br />
Phone: (262) 654-5333<br />
Fax: (262) 654-7818<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/01/1981<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2338<br />
IPC MENTAL HEALTH CENTERS<br />
GAYLE ROWE<br />
2717 N GRANDVIEW BLVD #202<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
gaylerowe@sbcglobal.net<br />
Phone: (262) 513-0700<br />
Fax: (262) 513-0707<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/09/2001<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2745<br />
IRON COUNTY HUMAN SERVICES DEPARTMENT<br />
AND ASSOCIATES COMM SUPPORT PROGRAM<br />
AMY SAARNIO WYKA<br />
300 TACONITE STREET, #201<br />
HURLEY, WI 54534<br />
County: Iron<br />
No Email Address Provided<br />
Phone: (715) 561-3636<br />
Fax: (715) 561-2128<br />
Surveyor: Bradley Jahr<br />
Services<br />
IPC MENTAL HEALTH CENTERS OAK<br />
HILL TERRACE<br />
1805 KENSINGTON DRIVE<br />
WAUKESHA, WI 53188<br />
01/01/2012 12/31/2013<br />
Tier 1<br />
12/01/2010<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2007<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2011 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 141 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2347<br />
IRON COUNTY HUMAN SERVICES DEPARTMENT<br />
AND ASSOCIATES<br />
CAROLYN KOLSON-JANOV<br />
300 TACONITE STREET, #201<br />
HURLEY, WI 54534<br />
County: Iron<br />
kolsonc@ironcountywi.org<br />
Phone: (715) 561-3636<br />
Fax: (715) 561-2128<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/2002<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
CSAS-Prevention with Telehealth DHS 75.04<br />
1446<br />
JACKIE NITSCHKE CENTER, INC.<br />
WILLIAM LABINE<br />
630 CHERRY STREET<br />
GREEN BAY, WI 54301<br />
County: Brown<br />
wlab<strong>in</strong>e@jackienitschkecenter.com<br />
Phone: (920) 435-2093<br />
Fax: (920) 435-2580<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
IRON COUNTY HUMAN SERVICES DEPT<br />
& ASSOC<br />
2567 RAILROAD STREET<br />
MERCER, WI 54547<br />
Tier 1<br />
03/01/2011<br />
02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/05/1990<br />
01/01/2011<br />
12/31/2012<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2901<br />
JACKSON COUNTY DEPARTMENT OF HEALTH<br />
AND HUMAN SERVICES<br />
CHRISTINE HOVELL<br />
420 HIGHWAY 54 WEST<br />
BLACK RIVER FALLS, WI 54615<br />
County: Jackson<br />
Beth.smetana@co.jackson.wi.us<br />
Phone: (715) 284-4301<br />
Fax: (715) 284-7713<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2010<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 142 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2957<br />
JACKSON COUNTY DEPT OF HEALTH & HUMAN<br />
SERVICES<br />
BETH SMETANA<br />
420 HIGHWAY 54 WEST<br />
BLACK RIVER FALLS, WI 54615<br />
County: Jackson<br />
beth.smetana@co.jackson.wi.us<br />
Phone: (715) 284-4301<br />
Fax: (715) 284-7713<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/2012<br />
01/01/2012<br />
12/31/2012<br />
CSAS-Intervention DHS 75.16<br />
1448<br />
JANESVILLE PSYCHIATRIC CLINIC<br />
BILL HOLLINGSWORTH<br />
15 WEST MILWAUKEE ST SUITE #207<br />
JANESVILLE, WI 53548<br />
County: Rock<br />
janesvillepsych@sbcglobal.net<br />
Phone: (608) 755-1475<br />
Fax: (608) 755-1733<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1981<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2221<br />
JEFFERSON COUNTY HUMAN SERVICES<br />
COMMUNITY SUPPORT PROGRAM<br />
MAJORIE THORMAN<br />
1541 ANNEX ROAD<br />
JEFFERSON, WI 53549<br />
County: Jefferson<br />
marjt@jeffersoncountywi.gov<br />
Phone: (920) 674-8198<br />
Fax: (920) 674-7409<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2000<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 143 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2643<br />
JEFFERSON COUNTY HUMAN SERVICES<br />
COMPREHENSIVE COMMUNITY SERVICES<br />
KIMBERLY PROPP<br />
1541 ANNEX ROAD<br />
JEFFERSON, WI 53549<br />
County: Jefferson<br />
kimp@jeffersoncountywi.gov<br />
Phone: (920) 674-8727<br />
Fax: (920) 674-2359<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/15/2006<br />
03/01/2011<br />
02/28/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
1449<br />
JEFFERSON COUNTY HUMAN SERVICES<br />
HOLLY PAGEL<br />
1541 ANNEX ROAD<br />
JEFFERSON, WI 53549<br />
County: Jefferson<br />
hollyp@jeffersoncountywi.gov<br />
Phone: (920) 674-3105<br />
Fax: (920) 674-6113<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
1450<br />
JEWISH FAMILY SERVICES<br />
JAMES WELSCH<br />
1300 N. JACKSON STREET<br />
MILWAUKEE, WI 53202<br />
County: Milwaukee<br />
jwelsch@jfsmilw.org<br />
Phone: (414) 390-5899<br />
Fax: (414) 225-1346<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1979<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
06/01/2012 05/31/2014<br />
06/01/2012 05/31/2014<br />
06/01/2012 05/31/2014<br />
JEWISH FAMILY SERVICES Tier 1<br />
5800 N BAYSHORE DRIVE<br />
06/01/2012<br />
GLENDALE, WI 53209<br />
05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 144 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2267<br />
JOHNSON COUNSELING AND CONSULTING<br />
JOHN JOHNSON<br />
505 KING STREET, #227<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
jjcounselor@centurytel.net<br />
Phone: (608) 796-2710<br />
Fax: (608) 796-2712<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/26/2000<br />
04/01/2011<br />
12/31/2012<br />
CSAS-Intervention DHS 75.16<br />
1598<br />
JOURNEY MENTAL HEALTH CENTER FORDEM<br />
CONNECTIONS CSP<br />
CORINDA RAINEY-MOORE<br />
2000 FORDEM AVENUE, 1ST FLOOR<br />
MADISON, WI 53704<br />
County: Dane<br />
No Email Address Provided<br />
Phone: (608) 280-3180<br />
Fax: (608) 280-3185<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1990<br />
01/01/2012<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1599<br />
JOURNEY MENTAL HEALTH CENTER GATEWAY<br />
COMMUNITY SUPPORT PROGRAM<br />
SUE MAURER<br />
1423 S PARK STREET<br />
MADISON, WI 53715<br />
County: Dane<br />
sue.maurer@mhcdc.org<br />
Phone: (608) 280-3150<br />
Fax: (608) 280-3160<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1990<br />
01/01/2012<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
01/01/2012 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 145 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1596<br />
JOURNEY MENTAL HEALTH CENTER INC<br />
LYNN BRADY<br />
625 W. WASHINGTON AVENUE<br />
MADISON, WI 53703<br />
County: Dane<br />
Lynn.brady@journeymhc.org<br />
Phone: (608) 280-2700<br />
Fax: (608) 280-2707<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1975<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1593<br />
JOURNEY MENTAL HEALTH CENTER-COMMUNITY<br />
TREATMENT ALTERNATIVES CSP<br />
DAVE DELAP<br />
708 WILLIAMSON STREET<br />
MADISON, WI 53703<br />
County: Dane<br />
dave.delap@mhcdc.org<br />
Phone: (608) 280-2740<br />
Fax: (608) 280-2775<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1992<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1595<br />
JOURNEY MENTAL HEALTH CENTER-YAHARA<br />
HOUSE<br />
GAIL MARKER<br />
802 E. GORHAM STREET<br />
MADISON, WI 53703<br />
County: Dane<br />
gail.marker@journeymhc.org<br />
Phone: (608) 280-4700<br />
Fax: (608) 280-4730<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
01/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
NO BRANCH LOCATIONS<br />
02/01/2012 01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 01/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 146 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1000<br />
JOY OF LIFE CENTER, LTD.<br />
ALEX WALKOWIAK<br />
721 S. 2ND STREET<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
centpos@ticon.net<br />
Phone: (414) 382-9168<br />
Fax: (414) 382-9667<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/01/1979<br />
07/01/2009<br />
06/30/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2652<br />
JULIE A FEIDER, MSE, LPC<br />
JULIE A FEIDER<br />
401 W NORTH WATER STREET<br />
NEW LONDON, WI 54961<br />
County: Waupaca<br />
juliefeider@sbcglobal.net<br />
Phone: (920) 982-2289<br />
Fax: (920) 982-2888<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/15/2006<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1453<br />
JUNEAU COUNTY DEPARTMENT OF HUMAN<br />
SERVICES<br />
DAVID RUNG<br />
220 E LACROSSE STREET, ROOM 23<br />
MAUSTON, WI 53948<br />
County: Juneau<br />
drung@co.juneau.wi.us<br />
Phone: (608) 847-2400<br />
Fax: (608) 847-9421<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2009 06/30/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1988<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 147 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1452<br />
JUNEAU COUNTY DEPARTMENT OF HUMAN<br />
SERVICES-COMMUNITY SUPPORT PROGRAM<br />
MARY JO ONSAGER<br />
220 E. LACROSSE STREET<br />
MAUSTON, WI 53948<br />
County: Juneau<br />
monsager@co.juneau.wi.us<br />
Phone: (608) 847-2400<br />
Fax: (608) 847-9421<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1989<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2486<br />
JUVENILE ASSESSMENT AND TREATMENT<br />
CENTER, LLC<br />
LORRIE ROLLER<br />
2453 ATWOOD AVENUE, #102<br />
MADISON, WI 53704<br />
County: Dane<br />
roller.jatc@sbcglobal.net<br />
Phone: (608) 242-8780<br />
Fax: (608) 242-8790<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2003<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1454<br />
KA'NI KUHLI'YO FAMILY CENTER<br />
MARI KRIESCHER<br />
2640 WEST POINT ROAD<br />
GREEN BAY, WI 54303<br />
County: Brown<br />
mkriesch@oneidanation.org<br />
Phone: (920) 490-3737<br />
Fax: (920) 490-3858<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/11/1993<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
01/01/2011 11/30/2012<br />
12/01/2010 12/31/2010<br />
ONEIDA COMMUNITY HEALTH CENTER Tier 1<br />
525 AIRPORT DRIVE, PO BOX 365<br />
02/01/2011<br />
ONEIDA, WI 54155<br />
01/31/2013<br />
SEYMOUR SCHOOL SYSTEM Tier 1<br />
10 CIRCLE DRIVE<br />
02/01/2011<br />
SEYMOUR, WI 54165<br />
01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 148 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1014<br />
KARE CENTER<br />
JEANNINE M FIELD<br />
510 - 60TH STREET<br />
KENOSHA, WI 53140<br />
County: Kenosha<br />
jfield@khds.org<br />
Phone: (262) 654-3586<br />
Fax: (262) 653-2080<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/10/1987<br />
08/01/2012<br />
07/31/2014<br />
CSAS-Residential Intoxication Monitor<strong>in</strong>g DHS 75.09<br />
2601<br />
KAREN CARNABUCCI COMPANIONS IN HEALING<br />
KAREN CARNABUCCI<br />
932 LAKE AVENUE<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
karenc@wi.rr.com<br />
Phone: (262) 633-2645<br />
Fax: No Number Provided<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2005<br />
08/01/2008<br />
07/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1458<br />
KATHLEEN BAHLER & ASSOCIATES<br />
KATHLEEN BAHLER<br />
315 S. JEFFERSON STREET<br />
GREEN BAY, WI 54301<br />
County: Brown<br />
Kathleen@kathleenbahler.com<br />
Phone: (920) 435-1188<br />
Fax: (920) 435-0276<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1988<br />
01/01/2009<br />
12/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
08/01/2008 07/31/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2009 12/31/2010
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 149 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2589<br />
KENOSHA COUNTY DEPARTMENT OF HUMAN<br />
SERVICES COMPREHENSIVE COMMUNITY<br />
SERVICES<br />
GERALD A THEIS, LCSW<br />
5407 8TH AVENUE<br />
KENOSHA, WI 53140<br />
County: Kenosha<br />
jtheis@co.kenosha.wi.us<br />
Phone: (262) 697-6524<br />
Fax: (262) 697-4655<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/2005<br />
05/01/2011<br />
04/30/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
2897<br />
KENOSHA HUMAN DEVELOPMENT SERVICES, INC<br />
COMMUNITY SUPPORT PROGRAM<br />
LISA A HAEN, MS<br />
5407 - 8TH AVENUE<br />
KENOSHA, WI 53140<br />
County: Kenosha<br />
khds@khds.com<br />
Phone: (262) 657-7188<br />
Fax: (262) 653-2080<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2010<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1460<br />
KENOSHA HUMAN DEVELOPMENT SERVICES,<br />
INC.<br />
KARI FOSS<br />
5407 - 8TH AVENUE<br />
KENOSHA, WI 53140<br />
County: Kenosha<br />
kfoss@khds.org<br />
Phone: (262) 657-7188<br />
Fax: (262) 653-2080<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1977<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 150 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2894<br />
KETTLE MORAINE COUNSELING SERVICES<br />
DEVONA MARSHALL<br />
125 N 6TH AVENUE, #201<br />
WEST BEND, WI 53095<br />
County: Wash<strong>in</strong>gton<br />
devona@kettlemora<strong>in</strong>ecounsel<strong>in</strong>g.com<br />
Phone: (262) 334-4340<br />
Fax: (262) 334-4341<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/2010<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2288<br />
KEWAUNEE COUNTY DEPARTMENT OF HUMAN<br />
SERVICES CSP<br />
WILLIAM P KELSEY<br />
810 LINCOLN STREET<br />
KEWAUNEE, WI 54216<br />
County: Kewaunee<br />
seidlm@kewauneeco.org<br />
Phone: (920) 388-7030<br />
Fax: (920) 388-7044<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
KETTLE MORAINE COUNSELING Tier 2<br />
N62 W281 WASHINGTON AVENUE<br />
08/22/2011<br />
CEDARBURG, WI 53012<br />
02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1977<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1466<br />
KEWAUNEE COUNTY DEPARTMENT OF HUMAN<br />
SERVICES<br />
MARK SEIDL<br />
810 LINCOLN<br />
KEWAUNEE, WI 54216<br />
County: Kewaunee<br />
seidlm@kewauneeco.org<br />
Phone: (920) 388-7030<br />
Fax: (920) 388-7044<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1977<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Emergency Outpatent with Telehealth DHS 75.05<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 w/Telehealth DHS 34.3<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 151 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2781<br />
KEWAUNEE COUNTY DHS COMPREHENSIVE<br />
COMMUNITY SERVICES<br />
WILLIAM KELSEY<br />
810 LINCOLN STREET<br />
KEWAUNEE, WI 54216<br />
County: Kewaunee<br />
No Email Address Provided<br />
Phone: (920) 388-7030<br />
Fax: (920) 388-7044<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/11/2008<br />
04/01/2012<br />
03/31/2014<br />
Comprehensive Community Services (CCS) DHS 36<br />
2607<br />
KIDS IN TRANSITION, INC<br />
CLEON SUGGS<br />
6815 W CAPITOL DRIVE, #215<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
csuggs@mcw.edu<br />
Phone: (414) 688-3062<br />
Fax: (414) 277-8939<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2008<br />
03/01/2011<br />
10/31/2011<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1468<br />
KINNIC FALLS ALCOHOL AND DRUG ABUSE<br />
SERVICES, INC.<br />
JENNIFER BYRON<br />
900 S. ORANGE STREET<br />
RIVER FALLS, WI 54022<br />
County: Pierce<br />
JByron@k<strong>in</strong>nicfalls.org<br />
Phone: (715) 426-5950<br />
Fax: (715) 426-5763<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1990<br />
05/01/2012<br />
04/30/2013<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
03/01/2011 10/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 152 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1469<br />
KOINONIA<br />
JIM WEBB<br />
1991 WINNEBAGO STREET<br />
RHINELANDER, WI 54501<br />
County: Oneida<br />
jwebb@optionstx.com<br />
Phone: (715) 362-5745<br />
Fax: (715) 362-2819<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1986<br />
12/23/2011<br />
11/30/2012<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Residential Intoxication Monitor<strong>in</strong>g DHS 75.09<br />
2528<br />
KRAWCZYK COUNSELING SERVICES, LLC<br />
GAIL KRAWCZYK<br />
2631 S PACKERLAND DRIVE, #104C<br />
GREEN BAY, WI 54313<br />
County: Brown<br />
No Email Address Provided<br />
Phone: (920) 965-7701<br />
Fax: No Number Provided<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/23/2004<br />
08/31/2009<br />
06/30/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2250<br />
KRISS AND ASSOCIATES<br />
MARLIN KRISS<br />
6702 STONEFIELD ROAD, #100<br />
MIDDLETON, WI 53562<br />
County: Dane<br />
marl<strong>in</strong>.kriss<strong>and</strong>associates@gmail.com<br />
Phone: (608) 836-5529<br />
Fax: (608) 836-8059<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/23/2011 11/30/2012<br />
12/23/2011 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2000<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
08/31/2009 06/30/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2010 09/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 153 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2445<br />
KRISTINE L. CLARK- SETNESS, MS, LMFT, ATR,<br />
INC.<br />
KRISTINE L CLARK-SETNESS<br />
101 E. SADD STREET<br />
NORTH PRAIRIE, WI 53153<br />
County: Waukesha<br />
kcsetnes@aol.com<br />
Phone: (262) 392-5558<br />
Fax: (262) 392-5580<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/07/2003<br />
06/01/2008<br />
05/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1473<br />
KROHN CLINIC, LTD.<br />
SHERIE SPAULDING BH MGR<br />
610 W. ADAMS STREET<br />
BLACK RIVER FALLS, WI 54615<br />
County: Jackson<br />
spauld<strong>in</strong>gs@krohncl<strong>in</strong>ic.com<br />
Phone: (715) 284-1901<br />
Fax: (715) 284-1890<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1988<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1485<br />
LA CASA DE ESPERANZA, INC. OUTPATIENT<br />
CLINIC<br />
LEE WIPFLI, SAC<br />
210 N W BARSTOW ST, #110<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
lwipfli@lacasadeesperanza.org<br />
Phone: (262) 928-4402<br />
Fax: (262) 928-7340<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
06/01/2008 05/31/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1993<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 154 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2367<br />
LA CAUSA, INC.<br />
CHYRA TROST<br />
1212 S 70TH ST #115A<br />
WEST ALLIS, WI 53214<br />
County: Milwaukee<br />
chyrat@lacausa.org<br />
Phone: (414) 902-1551<br />
Fax: (414) 771-7497<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/22/2002<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2594<br />
LA CROSSE COUNTY HUMAN SERVICES<br />
COMPREHENSIVE COMMUNITY SERVICES<br />
MATT STRITTMATER<br />
300 N FOURTH STREET, NORTH<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
mstrittmater@lacrossecounty.org<br />
Phone: (608) 785-6156<br />
Fax: (608) 785-6133<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/20/2005<br />
08/01/2011<br />
07/31/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
1488<br />
LA CROSSE COUNTY HUMAN SERVICES<br />
JENNIFER TIMM<br />
300 N. 4TH STREET<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
jtimm@lacrossecounty.org<br />
Phone: (608) 785-6113<br />
Fax: (608) 785-6133<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1978<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
CRISIS ASSESSMENT RECOVERY<br />
EMPOWERMENT<br />
4647 MORMON COULEE ROAD<br />
LA CROSSE, WI 54601<br />
08/01/2011 07/31/2013<br />
Tier 1<br />
05/01/2012<br />
04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 155 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2935<br />
LA CROSSE COUNTY HUMAN SERVICES<br />
BECKY SPANJERS<br />
333 VINE STREET, ROOM 740<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
spanjers.becky@co.la-crosse.wi.us<br />
Phone: (608) 789-4895<br />
Fax: (608) 785-6562<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/19/2011<br />
05/01/2012<br />
04/30/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1486<br />
LAC COURTE ORIELLES COMMUNITY HEALTH<br />
CENTER<br />
JULIE YAEKEL-BLACK ELK<br />
13380 W. TREPANIA ROAD<br />
HAYWARD, WI 54843<br />
County: Sawyer<br />
jblackelk@lcohc.com<br />
Phone: (715) 638-5124<br />
Fax: (715) 634-6107<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1987<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2457<br />
LAD LAKE, INC.<br />
KARIE L LOWE<br />
225 W CAPITOL DRIVE<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 332-2690<br />
Fax: (414) 332-2875<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2003<br />
07/01/2010<br />
06/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2010 06/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 156 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2279<br />
LAFAYETTE COUNTY DEPARTMENT OF HUMAN<br />
SERVICES COMMUNITY SUPPORT PROGRAM<br />
SHANE SHUHMACHER<br />
627 N. MAIN STREET<br />
DARLINGTON, WI 53530<br />
County: Lafayette<br />
sschuhmacher@lchsd.org<br />
Phone: (608) 776-4909<br />
Fax: (608) 776-4914<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/2000<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1490<br />
LAFAYETTE COUNTY DEPARTMENT OF HUMAN<br />
SERVICES<br />
SHANE SCHUHMACHER<br />
627 N. MAIN STREET<br />
DARLINGTON, WI 53530<br />
County: Lafayette<br />
SSchuhmacher@lchsd.org<br />
Phone: (608) 776-4909<br />
Fax: (608) 776-4914<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
06/01/2011<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2756<br />
LAKE CITY COUNSELING, LLC<br />
BETH WHITTEMORE<br />
2829 ROYAL AVENUE, #200<br />
MADISON, WI 53713<br />
County: Dane<br />
beth@lakecitycounsel<strong>in</strong>g.com<br />
Phone: (608) 661-2829<br />
Fax: (608) 661-0907<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/15/2007<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
06/01/2011 10/31/2012<br />
06/01/2011 10/31/2012<br />
06/01/2011 10/31/2012<br />
06/01/2011 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2010 09/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 157 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2798<br />
LAKE COUNTRY COUNSELING SERVICES<br />
DIANE GARRISON, PHD<br />
325 FOREST GROVE DRIVE, #201<br />
PEWAUKEE, WI 53072<br />
County: Waukesha<br />
dgarrison@earthl<strong>in</strong>k.net<br />
Phone: (262) 691-2980<br />
Fax: (262) 691-2972<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/13/2008<br />
09/01/2011<br />
08/31/2012<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1492<br />
LAKE GENEVA WELLNESS CLINIC<br />
DEBRA NELSON<br />
101 BROAD STREET, #201<br />
LAKE GENEVA, WI 53147<br />
County: Walworth<br />
lakegenevawellnesscl<strong>in</strong>ic@yahoo.com<br />
Phone: (262) 248-7942<br />
Fax: (262) 248-1202<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1984<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2934<br />
LAKEVIEW CARE PARTNERS WISCONSIN<br />
JIM PARA-CREMER<br />
507 MARKET STREET<br />
WESTFIELD, WI 53964<br />
County: Marquette<br />
jparacremer@lakeview.ws<br />
Phone: (262) 534-8582<br />
Fax: (262) 534-7257<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2011 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/14/2011<br />
02/01/2012<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 158 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2890<br />
LANGLADE HOSPITAL GENERAL CLINIC<br />
SYLVIA DENNISON MD<br />
110 E FIFTH AVENUE<br />
ANTIGO, WI 54409<br />
County: Langlade<br />
sylviad@aspirus.org<br />
Phone: (715) 623-2351<br />
Fax: (715) 627-6124<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/27/2010<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
2466<br />
LARSON COUNSELING<br />
PAULA W LARSON<br />
2631 S PACKERLAND DRIVE #104F<br />
GREEN BAY, WI 54303<br />
County: Brown<br />
MsLars2@aol.com<br />
Phone: (920) 884-1144<br />
Fax: (920) 336-5959<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/28/2003<br />
09/01/2009<br />
08/31/2010<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2354<br />
LAUREN MURPHY PAYNE & ASSOCIATES, LLC<br />
LAUREN MURPHY PAYNE<br />
6021 DURAND AVENUE, #300<br />
RACINE, WI 53406<br />
County: Rac<strong>in</strong>e<br />
lmp<strong>and</strong>assoc@sbcglobal.net<br />
Phone: (262) 554-0126<br />
Fax: (262) 554-0127<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2002<br />
03/01/2009<br />
02/28/2011<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
09/01/2009 08/31/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2009 02/28/2011
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 159 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2046<br />
LEES PSYCHOLOGICAL SERVICES, INC.<br />
LAURA A. LEES, PSYD<br />
601 N 99TH STREET, #307<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
heart<strong>and</strong>m<strong>in</strong>dmatters.com<br />
Phone: (414) 774-6878<br />
Fax: (414) 774-6879<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/25/1998<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2869<br />
LEPAK-JOSTSONS, INC DBA DYNAMIC FAMILY<br />
SOLUTIONS<br />
JANE A LEPAK-JOSTSONS<br />
615 SOUTH 8TH ST SUITE 220<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
dfsjanelepakjostsons@excel.net<br />
Phone: (920) 323-2188<br />
Fax: (920) 358-5970<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/19/2009<br />
09/01/2012<br />
08/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2113<br />
LIBERTAS OF MARINETTE<br />
PATRICK RYAN<br />
1712 DUNLAP SQUARE BLDG, #5<br />
MARINETTE, WI 54143<br />
County: Mar<strong>in</strong>ette<br />
pryan@sjcf.hshs.org<br />
Phone: (715) 735-0095<br />
Fax: (715) 735-0094<br />
Surveyor: Frank Bellaire<br />
Services<br />
10/01/2011 09/30/2013<br />
DYNAMIC FAMILY SOLUTIONS Tier 1<br />
W1236 HWY FF<br />
09/01/2012<br />
HAVEN, WI 53083<br />
08/31/2014<br />
DYNAMIC FAMILY SOLUTIONS Tier 2<br />
ONE WALDO BLVD SUITE 3<br />
09/01/2012<br />
MANITOWOC, WI 54220<br />
08/31/2014<br />
DYNAMIC FAMILY SOLUTIONS Tier 2<br />
3021 HOLMGREN WAY<br />
09/01/2012<br />
GREEN BAY, WI 54305<br />
08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/18/1999<br />
06/01/2012<br />
05/31/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
09/01/2012 08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 160 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1504<br />
LIBERTAS OF SHEBOYGAN<br />
PATRICK RYAN<br />
2108 KOHLER MEMORIAL DRIVE<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
pryan@sjcf.hshs.org<br />
Phone: (920) 803-0740<br />
Fax: (920) 803-0739<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/16/1988<br />
04/01/2011<br />
03/31/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1505<br />
LIBERTAS TREATMENT CENTER<br />
PATRICK RYAN<br />
1701 DOUSMAN STREET<br />
GREEN BAY, WI 54303<br />
County: Brown<br />
pryan@sjcf.hshs.org<br />
Phone: (920) 498-8600<br />
Fax: (920) 496-2027<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1986<br />
04/01/2011<br />
03/31/2013<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Medically Managed Inpatient Treatment DHS 75.10<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2661<br />
LIBERTY COUNSELING & WELLNESS CENTER<br />
CHAR GROVES<br />
151 E PARK AVENUE<br />
BERLIN, WI 54923<br />
County: Green Lake<br />
charlotgrov@aol.com<br />
Phone: (920) 290-0107<br />
Fax: (920) 361-2334<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/06/2006<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
LIBERTY COUNSELING Tier 1<br />
489 SCOTT STREET<br />
05/01/2011<br />
GREEN LAKE, WI 54941<br />
04/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 161 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2677<br />
LIFE POINT COUNSELING, LLC<br />
KATHLYN M HUNHOLZ<br />
433 A EAST MILL STREET<br />
PLYMOUTH, WI 53073<br />
County: Sheboygan<br />
lifepo<strong>in</strong>t@verizon.net<br />
Phone: (920) 892-7606<br />
Fax: (920) 449-4247<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/06/2006<br />
08/01/2012<br />
07/31/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1507<br />
LIFE SPAN PSYCHOLOGICAL SERVICES, LLC<br />
THOMAS S. LEHMANN<br />
13035 W BLUEMOUND ROAD, #100<br />
BROOKFIELD, WI 53005<br />
County: Waukesha<br />
lifespan7777@yahoo.com<br />
Phone: (262) 784-1121<br />
Fax: (262) 784-9777<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1989<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1509<br />
LIGHTHOUSE CLINIC, LLC<br />
MARGO RENNER<br />
2524 E WEBSTER PLACE, #203<br />
MILWAUKEE, WI 53211<br />
County: Milwaukee<br />
lighthousecl<strong>in</strong>ic@gmail.com<br />
Phone: (414) 964-9200<br />
Fax: (414) 964-4816<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
LIFE-SPAN PSYCHOLOGICAL SERVICES,<br />
LLC<br />
2266 N PROSPECT AVENUE, #503<br />
MILWAUKEE, WI 53202<br />
LIFE-SPAN PSYCHOLOGICAL SERVICES,<br />
LLC<br />
11803 W NORTH AVENUE<br />
MILWAUKEE, WI 53226<br />
08/01/2012 07/31/2014<br />
Tier 1<br />
11/01/2011<br />
10/31/2013<br />
Tier 1<br />
11/01/2011<br />
10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1990<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
LIGHTHOUSE CLINIC Tier 1<br />
11520 N PT WASHINGTON ROAD<br />
02/01/2012<br />
MEQUON, WI 53092<br />
01/31/2014<br />
LIGHTHOUSE CLINIC Tier 1<br />
11803 W NORTH AVENUE, #207<br />
02/01/2012<br />
MILWAUKEE, WI 53226<br />
01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 01/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 162 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2597<br />
LIVING HOPE CHRISTIAN COUNSELING<br />
JOHN C JOHNSON<br />
2066 LAWRENCE DRIVE<br />
DE PERE, WI 54115<br />
County: Brown<br />
jcjohnson@liv<strong>in</strong>ghopellc.org<br />
Phone: (920) 338-8699<br />
Fax: (920) 336-3181<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/12/2005<br />
09/01/2012<br />
08/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2778<br />
LIVING WELL CHRISTIAN FAMILY CLINIC, LLC<br />
PHILIP KOESTLER<br />
1285 RUDY STREET, #102<br />
ONALASKA, WI 54650<br />
County: La Crosse<br />
staff@liv<strong>in</strong>gwellcfc.com<br />
Phone: (608) 783-1452<br />
Fax: (608) 783-1456<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2008<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2393<br />
LSS HOMME YOUTH AND FAMILY PROGRAMS,<br />
LSS HOMME OUTPATIENT CLINIC<br />
GREG ROBBINS<br />
W18105 HEMLOCK ROAD<br />
WITTENBERG, WI 54499<br />
County: Shawano<br />
grobb<strong>in</strong>s@lsswis.org<br />
Phone: (715) 253-2116<br />
Fax: (715) 253-3188<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2012 08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/27/2002<br />
01/04/2008<br />
01/31/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/04/2008 01/31/2009
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 163 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2797<br />
LSS OF WI & UPPER MI FAMILY PRESERVATION<br />
PROGRAM<br />
MIKE BAUER<br />
120 S BARSTOW STREET<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
mbauer@lsswis.org<br />
Phone: (715) 832-2221<br />
Fax: (715) 838-8423<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/30/2008<br />
07/01/2012<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
LSS OF WI & UPPER MI FAMILY<br />
PRESERVATION<br />
115 N 6TH STREET<br />
WAUSAU, WI 54403<br />
Tier 1<br />
07/01/2012<br />
06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 164 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1516<br />
LUTHERAN COUNSELING AND FAMILY SERVICES<br />
OF WISCONSIN<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 165 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
CHUCK MESECK<br />
3800 N. MAYFAIR ROAD<br />
WAUWATOSA, WI 53222<br />
County: Milwaukee<br />
lcfs@lcfswi.org<br />
Phone: (414) 536-8333<br />
Fax: (414) 536-8348<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1978<br />
04/01/2012<br />
03/31/2014<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
LCFS-ST JOHN LUTHERAN CHURCH Tier 1<br />
4850 S LAKE DRIVE<br />
04/01/2012<br />
CUDAHY, WI 53110<br />
03/31/2014<br />
LCFS-ST PAUL LUTHERAN CHURCH Tier 1<br />
210 E PLEASANT ST<br />
04/01/2012<br />
OCONOMOWOC, WI 53066<br />
03/31/2014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
Tier 1<br />
345 NORTH PINE ST<br />
04/01/2012<br />
REEDSBURG, WI 53959<br />
03/31/2014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
Tier 1<br />
1228 S. PARK AVENUE<br />
04/01/2012<br />
NEENAH, WI 54956<br />
03/31/2014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
Tier 1<br />
850 ARMSTRONG STREET<br />
04/01/2012<br />
PORTAGE, WI 53901<br />
03/31/2014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
Tier 1<br />
15 E. SAWYER STREET<br />
04/01/2012<br />
RICE LAKE, WI 54868<br />
03/31/2014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
Tier 1<br />
324 S. ANDREWS STREET<br />
04/01/2012<br />
SHAWANO, WI 54166<br />
03/31/2014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
Tier 1<br />
1614 S. 23RD STREET<br />
04/01/2012<br />
SHEBOYGAN, WI 53081<br />
03/31/2014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
Tier 1<br />
1756 MICHIGAN STREET<br />
04/01/2012<br />
STURGEON BAY, WI 54235<br />
03/31/2014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
Tier 1<br />
300 BROADWAY DRIVE<br />
04/01/2012<br />
SUN PRAIRIE, WI 53590<br />
03/31/2014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
Tier 1<br />
536 SOUTH FIFTH AVENUE<br />
04/01/2012<br />
WAUSAU, WI 54401<br />
03/31/2014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
Tier 1<br />
260 VINCENT ST<br />
04/01/2012<br />
FOND DU LAC, WI 54935<br />
03/31/2014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
Tier 1<br />
701 WASHINGTON ST<br />
04/01/2012<br />
GRAFTON, WI 53024<br />
03/31/2014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
Tier 1
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 166 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2428<br />
LUTHERAN SOCIAL SERVICES - OZAUKEE<br />
TERI GUMIENY<br />
13460 N PORT WASHINGTON ROAD<br />
MEQUON, WI 53097<br />
County: Ozaukee<br />
teri.gumieny@lsswis.org<br />
Phone: (262) 377-2902<br />
Fax: (414) 645-7850<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
210 S. ONEIDA STREET<br />
GREEN BAY, WI 54303<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
168 MOUND STREET<br />
BERLIN, WI 54923<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
2833 RARITAN<br />
FITCHBURG, WI 53711<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
601 FALL STREET<br />
EAU CLAIRE, WI 54703<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
717 MEMORIAL DRIVE<br />
CHILTON, WI 53014<br />
LUTHERAN COUNSELING & FAMILY<br />
SERVICES OF WI<br />
107 N. STATE STREET<br />
MERRILL, WI 54452<br />
04/01/2012<br />
03/31/2014<br />
Tier 1<br />
04/01/2012<br />
03/31/2014<br />
Tier 1<br />
04/01/2012<br />
03/31/2014<br />
Tier 1<br />
04/01/2012<br />
03/31/2014<br />
Tier 1<br />
04/01/2012<br />
03/31/2014<br />
Tier 1<br />
04/01/2012<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2002<br />
08/06/2009<br />
11/30/2010<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/06/2009 11/30/2010
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 167 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1544<br />
LUTHERAN SOCIAL SERVICES - WAUKESHA<br />
TERI GUMIENY<br />
2000 BLUEMOUND ROAD<br />
WAUKESHA, WI 53186<br />
County: Waukesha<br />
teri.gumieny@lsswis.org<br />
Phone: (262) 896-3440<br />
Fax: (414) 645-7850<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1989<br />
12/01/2008<br />
11/30/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1525<br />
LUTHERAN SOCIAL SERVICES AT THOMPSON<br />
COMMUNITY CENTER<br />
BETH BELMORE<br />
820 W. COLLEGE AVENUE, #1<br />
APPLETON, WI 54914<br />
County: Outagamie<br />
No Email Address Provided<br />
Phone: (920) 733-2860<br />
Fax: (920) 834-2824<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
LUTHERAN SOCIAL SERVICES -<br />
WAUKESHA<br />
720 W ROCHESTER<br />
MUKWONAGO, WI 53149<br />
Tier 1<br />
12/01/2008<br />
11/30/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/20/1996<br />
10/01/2008<br />
09/30/2010<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1420<br />
LUTHERAN SOCIAL SERVICES HOUSE OF HOPE<br />
TERRI ELLZEY<br />
325 SENTINEL DRIVE<br />
WAUKESHA, WI 53189<br />
County: Waukesha<br />
No Email Address Provided<br />
Phone: (262) 542-2663<br />
Fax: (262) 542-0732<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2008 11/30/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1994<br />
01/01/2009<br />
12/31/2010<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
10/01/2008 09/30/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2009 12/31/2010
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 168 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1534<br />
LUTHERAN SOCIAL SERVICES OF WI & UPPER MI,<br />
INC. MILWAUKEE CLINIC<br />
TERI GUMIENY<br />
155 E SILVER SPRING DRIVE, #201<br />
WHITEFISH BAY, WI 53217<br />
County: Milwaukee<br />
teri.gumieny@lsswis.org<br />
Phone: (414) 967-3902<br />
Fax: (414) 967-9783<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1997<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1545<br />
LUTHERAN SOCIAL SERVICES OF WISCONSIN &<br />
UPPER MICHIGAN-WAUSAU<br />
SIGNA MEYERS<br />
115 SIXTH STREET<br />
WAUSAU, WI 54403<br />
County: Marathon<br />
signa.meyers@lsswis.org<br />
Phone: (920) 225-1710<br />
Fax: (920) 734-2824<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
LUTHERAN SOCIAL SERVICES-RACINE Tier 1<br />
2219 WASHINGTON AVENUE<br />
04/01/2011<br />
RACINE, WI 53403<br />
03/31/2012<br />
LUTHERAN SOCIAL<br />
SERVICES-WAUKESHA<br />
Tier 1<br />
2000 BLUEMOUND<br />
04/01/2011<br />
WAUKESHA, WI 53186<br />
03/31/2013<br />
OZAUKEE COUNSELING Tier 1<br />
13460 N PT WASHINGTON ROAD<br />
04/01/2011<br />
MEQUON, WI 53097<br />
03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1982<br />
07/01/2011<br />
06/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011 06/30/2012<br />
07/01/2011 06/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 169 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1542<br />
LUTHERAN SOCIAL SERVICES OF WISCONSIN<br />
AND UPPER MICHIGAN, INC.<br />
JOHN BALL<br />
33 NORTH 25TH STREET EAST<br />
SUPERIOR, WI 54880<br />
County: Douglas<br />
john.ball@lsswis.org<br />
Phone: (715) 394-4173<br />
Fax: (715) 394-9182<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/12/1998<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 170 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2872<br />
LUTHERAN SOCIAL SERVICES<br />
SIGNA MEYERS<br />
3003-A NORTH RICHMOND ST<br />
APPLETON, WI 54911<br />
County: Outagamie<br />
signa.meyers@lsswis.org<br />
Phone: (920) 730-1330<br />
Fax: (920) 734-2824<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/02/2009<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
LUTHERAN SOCIAL SERVICES Tier 1<br />
706 N 9TH STREET<br />
08/01/2012<br />
SHEBOYGAN, WI 53081<br />
07/31/2014<br />
LUTHERAN SOCIAL SERVICES Tier 1<br />
901 HARRISON DRIVE<br />
08/01/2012<br />
BELOIT, WI 53511<br />
07/31/2014<br />
LUTHERAN SOCIAL SERVICES Tier 2<br />
820 W COLLEGE AVENUE<br />
08/01/2012<br />
APPLETON, WI 54914<br />
07/31/2014<br />
LUTHERAN SOCIAL SERVICES Tier 2<br />
612 N RANDALL STREET<br />
08/01/2012<br />
JANESVILLE, WI 53545<br />
07/31/2014<br />
LUTHERAN SOCIAL SERVICES Tier 2<br />
6314 ODANA ROAD<br />
08/01/2012<br />
MADISON, WI 53719<br />
07/31/2014<br />
LUTHERAN SOCIAL SERVICES Tier 1<br />
550 LINCOLN DRIVE<br />
08/01/2012<br />
SUN PRAIRIE, WI 53590<br />
07/31/2014<br />
LUTHERAN SOCIAL SERVICES Tier 2<br />
809 N PARK AVENUE<br />
08/01/2012<br />
BEAVER DAM, WI 53916<br />
07/31/2014<br />
LUTHERAN SOCIAL SERVICES Tier 1<br />
115 NORTH 6TH STREET<br />
08/01/2012<br />
WAUSAU, WI 54403<br />
07/31/2014<br />
LUTHERAN SOCIAL SERVICES Tier 1<br />
727 - 8TH STREET<br />
08/01/2012<br />
BARABOO, WI 53913<br />
07/31/2014<br />
LUTHERAN SS ALCOHOL & DRUG<br />
RESOUCE CTR<br />
Tier 1<br />
131 S MAIN STREET<br />
08/01/2012<br />
FOND DU LAC, WI 54935<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 171 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1529<br />
LUTHERAN SOCIAL SERVICES-FAHRMAN CENTER<br />
RICHARD WILLIAMS<br />
3136 CRAIG ROAD<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
dwilliam@lsswis.org<br />
Phone: (715) 835-9110<br />
Fax: (715) 830-4098<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1986<br />
07/01/2012<br />
06/30/2014<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
1539<br />
LUTHERAN SOCIAL SERVICES-RACINE<br />
TERI GUMIENY<br />
2219 WASHINGTON AVENUE<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
teri.gumieny@lsswis.org<br />
Phone: (262) 637-3886<br />
Fax: (414) 645-7850<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1989<br />
12/01/2008<br />
11/30/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2130<br />
LUTHERAN SOCIAL SERVICES-TOUCHSTONES<br />
CENTER<br />
MARGARET BEHNKE<br />
122 SOUTH BARSTOW ST SUITE 1<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
margaret.benke@lsswis.org<br />
Phone: (715) 855-1373<br />
Fax: (715) 855-1375<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1999<br />
07/01/2012<br />
06/30/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
12/01/2008 11/30/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 172 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1546<br />
M & S CLINICAL SERVICES, INC.<br />
MARK FOSSIE<br />
2821 N 4TH STREET, #516<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
mscl<strong>in</strong>ical516@sbcglobal.net<br />
Phone: (414) 263-6000<br />
Fax: (414) 263-2270<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/04/1996<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1547<br />
M. BURTON PSYCHOLOGICAL SERVICES<br />
MARIANNE BURTON<br />
11035 W. FOREST HOME AVENUE<br />
HALES CORNERS, WI 53130<br />
County: Milwaukee<br />
drmburton@gmail.com<br />
Phone: (414) 425-2258<br />
Fax: No Number Provided<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1994<br />
11/01/2007<br />
10/31/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1549<br />
MADISON HEALTH SERVICES<br />
CHAD REDMAN<br />
3113 E. WASHINGTON AVENUE<br />
MADISON, WI 53704<br />
County: Dane<br />
credman@crchealth.com<br />
Phone: (608) 242-0220<br />
Fax: (608) 242-1166<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
06/13/2012 02/28/2013<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1994<br />
07/01/2012<br />
06/30/2014<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
11/01/2007 10/31/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 173 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1550<br />
MADISON MENTAL HEALTH SERVICES<br />
JAMES MCGLOIN<br />
702 N BLACKHAWK AVENUE, #104<br />
MADISON, WI 53705<br />
County: Dane<br />
jmcglo<strong>in</strong>@wisc.edu<br />
Phone: (608) 231-2008<br />
Fax: (608) 231-2312<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/1981<br />
04/01/2009<br />
06/30/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1553<br />
MADISON PSYCHOTHERAPY CENTER, LLC<br />
MARY ELLEN MILLER<br />
702 N BLACKHAWK AVENUE, #205<br />
MADISON, WI 53705<br />
County: Dane<br />
maryellmiller@frontier.com<br />
Phone: (608) 233-3037<br />
Fax: (608) 233-5893<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
MADISON MENTAL HEALTH SERVICES Tier 1<br />
715 HILL ST<br />
04/01/2009<br />
MADISON, WI 53705<br />
06/30/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1993<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1554<br />
MAEHNOWESEKIYAH WELLNESS CENTER<br />
SHANNON WILBER<br />
N2150 KESAEHKAHTEK<br />
GRESHAM, WI 54128<br />
County: Shawano<br />
No Email Address Provided<br />
Phone: (715) 799-3835<br />
Fax: (715) 799-3836<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2009 06/30/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/21/1989<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
NO BRANCH LOCATIONS<br />
10/01/2010 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 174 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2399<br />
MALEN & ASSOCIATES<br />
No Contact Name Provided<br />
759 N. MILWAUKEE STREET, #200<br />
MILWAUKEE, WI 53202<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 271-1718<br />
Fax: No Number Provided<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/2002<br />
08/01/2007<br />
07/31/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2285<br />
MANITOWOC COUNTY HUMAN SERVICES<br />
DEPARTMENT CSP<br />
JEFF JENSWOLD<br />
926 S. 8TH STREET<br />
MANITOWOC, WI 54221<br />
County: Manitowoc<br />
humanservices@co.manitowoc.wi.us<br />
Phone: (920) 683-4300<br />
Fax: (920) 683-4243<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
12/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Com Support Program w/Telehealth DHS 63<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1555<br />
MANITOWOC COUNTY HUMAN SERVICES<br />
DEPARTMENT<br />
JEFF JENSWOLD<br />
926 S. 8TH STREET<br />
MANITOWOC, WI 54221<br />
County: Manitowoc<br />
humanservices@co.manitowoc.wi.us<br />
Phone: (920) 683-4300<br />
Fax: (920) 683-4243<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2007 07/31/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
12/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
12/01/2011 10/31/2013<br />
12/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011 10/31/2013<br />
12/01/2011 10/31/2013<br />
12/01/2011 10/31/2013<br />
12/01/2011 10/31/2013<br />
12/01/2011 10/31/2013<br />
12/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 175 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2711<br />
MANITOWOC COUNTY HUMAN SERVICES DEPT<br />
COMPREHENSIVE COMMUNITY SERVICES<br />
DAVID SCHIBLINE<br />
926 S. 8TH STREET<br />
MANITOWOC, WI 54221<br />
County: Manitowoc<br />
davidschibl<strong>in</strong>e@co.manitowoc.wi.us<br />
Phone: (920) 683-4230<br />
Fax: (920) 683-4243<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/06/2007<br />
03/01/2011<br />
02/28/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
1556<br />
MANOS, SMITH AND ASSOCIATES<br />
DAVID SMITH<br />
407 PILOT COURT, #400<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
thethotdoctor@gmail.com<br />
Phone: (262) 524-9822<br />
Fax: (262) 832-0089<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1990<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2697<br />
MAPLEGROVE TREATMENT CENTER<br />
TIM KABARA<br />
1827 RIVER LAKES RD S<br />
OCONOMOWOC, WI 53066<br />
County: Waukesha<br />
timkabara@yahoo.com<br />
Phone: (262) 510-4447<br />
Fax: (262) 200-2808<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/28/2006<br />
12/01/2009<br />
11/30/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
10/01/2011 09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2009 11/30/2011
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 176 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1557<br />
MARCO SERVICES, INC.<br />
CRAIG PAULY<br />
1114 S. 11TH STREET<br />
MANITOWOC, WI 54220<br />
County: Manitowoc<br />
director@marcoservices.org<br />
Phone: (920) 684-0605<br />
Fax: (920) 684-0605<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/10/1990<br />
10/01/2009<br />
09/30/2011<br />
CSAS-Transitional Residential DHS 75.14<br />
2966<br />
MARINETTE COUNTY HEALTH & HUMAN<br />
SERVICES CCS<br />
ELLIE JARVIE<br />
2500 HALL AVENUE SUITE B<br />
MARINETTE, WI 54143<br />
County: Mar<strong>in</strong>ette<br />
ejarvie@mar<strong>in</strong>ettecounty.com<br />
Phone: (715) 732-7700<br />
Fax: (715) 732-7767<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012<br />
08/01/2012<br />
07/31/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
2340<br />
MARINETTE COUNTY HEALTH & HUMAN<br />
SERVICES DEPARTMENT/ADAPT CSP<br />
ROBIN ELSNER, MSW<br />
2500 HALL AVENUE, #A<br />
MARINETTE, WI 54143<br />
County: Mar<strong>in</strong>ette<br />
relsner@mar<strong>in</strong>ettecounty.com<br />
Phone: (715) 732-7760<br />
Fax: (715) 732-7711<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2009 09/30/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1982<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011 11/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 177 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1559<br />
MARINETTE COUNTY HEALTH & HUMAN<br />
SERVICES DEPARTMENT/ADAPT<br />
ROBIN ELSNER, MSW<br />
2500 HALL AVENUE, #A<br />
MARINETTE, WI 54143<br />
County: Mar<strong>in</strong>ette<br />
rvalent<strong>in</strong>e@mar<strong>in</strong>ettecounty.com<br />
Phone: (715) 732-7760<br />
Fax: (715) 732-7711<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1982<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Emergency Outpatent with Telehealth DHS 75.05<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 w/Telehealth DHS 34.3<br />
2321<br />
MARINETTE COUNTY HEALTH AND HUMAN<br />
SERVICES/ADAPT<br />
ROBIN ELSNER<br />
2135 PIERCE AVE<br />
MARINETTE, WI 54143<br />
County: Mar<strong>in</strong>ette<br />
No Email Address Provided<br />
Phone: (715) 732-7760<br />
Fax: (715) 732-7711<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
MARINETTE COUNTY HHSD/ADAPT Tier 1<br />
1201 JACKSON STREET<br />
12/01/2011<br />
NIAGARA, WI 54151<br />
11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/20/2001<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2322<br />
MARINETTE COUNTY HEALTH AND HUMAN<br />
SERVICES/ADAPT<br />
ROBIN ELSNER<br />
1011 WATER STREET<br />
MARINETTE, WI 54143<br />
County: Mar<strong>in</strong>ette<br />
No Email Address Provided<br />
Phone: (715) 732-7760<br />
Fax: (715) 732-7711<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/20/2001<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 178 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1560<br />
MARQUETTE CHEMICAL DEPENDENCY SERVICES<br />
BRUCE NICHOLAS<br />
428 UNDERWOOD AVE<br />
MONTELLO, WI 53949<br />
County: Marquette<br />
B.nicholashh@gmail.com<br />
Phone: (608) 297-2085<br />
Fax: (608) 297-2426<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1981<br />
05/01/2012<br />
04/30/2014<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
2424<br />
MARRIAGE & FAMILY HEALTH SERVICES, LTD.<br />
THOMAS JOHNSTON<br />
405 ISLAND STREET<br />
CHIPPEWA FALLS, WI 54729<br />
County: Chippewa<br />
chippewafallsmikan@att.net<br />
Phone: (715) 726-9208<br />
Fax: (715) 726-8731<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2003<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2738<br />
MARRIAGE & FAMILY SOLUTIONS LLC<br />
CRYSTAL DALEBROUX<br />
7818 BIG SKY DRIVE, #101<br />
MADISON, WI 53719<br />
County: Dane<br />
marriage.solutions@sbcglobal.net<br />
Phone: (608) 203-6267<br />
Fax: (608) 203-6696<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/08/2007<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2011 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 179 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1562<br />
MARRIAGE AND FAMILY HEALTH SERVICES, LTD.<br />
THOMAS JOHNSTON<br />
2925 MONDOVI ROAD<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
ecmikan@sbcglobal.net<br />
Phone: (715) 832-0238<br />
Fax: (715) 832-0771<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1983<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
MARRIAGE & FAMILY HEALTH SVS Tier 1<br />
104 WEST WASHINGTON AVE<br />
09/02/2012<br />
BRUCE, WI 54819<br />
04/30/2014<br />
MARRIAGE & FAMILY HEALTH SVS Tier 1<br />
604 7TH AVE EAST<br />
05/01/2012<br />
DURAND, WI 54736<br />
04/30/2014<br />
MARRIAGE & FAMILY HEALTH SVS Tier 1<br />
1700 EDGEWOOD AVE EAST<br />
05/01/2012<br />
LADYSMITH, WI 54848<br />
04/30/2014<br />
MARRIAGE & FAMILY HEALTH SVS Tier 1<br />
500 MAIN ST<br />
05/01/2012<br />
EAU CLAIRE, WI 54701<br />
04/30/2014<br />
MARRIAGE & FAMILY HEALTH SVS Tier 1<br />
1130 MILES ST<br />
05/01/2012<br />
CHIPPEWA FALLS, WI 54729<br />
04/30/2014<br />
MARRIAGE & FAMILY HEALTH SVS Tier 1<br />
W21772 US HWY 10<br />
05/01/2012<br />
STRUM, WI 54770<br />
04/30/2014<br />
MARRIAGE AND FAMILY HEALTH<br />
SERVICES LTD<br />
Tier 1<br />
905 - 7TH AVE WEST<br />
05/01/2012<br />
DURAND, WI 54736<br />
04/30/2014<br />
MARRIAGE AND FAMILY HEALTH<br />
SERVICES LTD<br />
Tier 1<br />
250 BUFFALO STREET<br />
05/01/2012<br />
MONDOVI, WI 54755<br />
04/30/2014<br />
MARRIAGE AND FAMILY HEALTH<br />
SERVICES, LTD<br />
Tier 1<br />
1301 COULEE ROAD<br />
05/01/2012<br />
HUDSON, WI 54016<br />
04/30/2014<br />
MARRIAGE AND FAMILY HEALTH<br />
SERVICES, LTD<br />
Tier 1<br />
612 E WARDEN AVENUE<br />
05/01/2012<br />
LADYSMITH, WI 54848<br />
04/30/2014<br />
MARRIAGE AND FAMILY HEALTH<br />
SERVICES, LTD.<br />
Tier 1<br />
P O BOX 517407 S 2ND STREET<br />
05/01/2012<br />
ALMA, WI 54610<br />
04/30/2014<br />
MARRIAGE AND FAMILY HEALTH<br />
SERVICES, LTD.<br />
Tier 1<br />
1109 HEART ISLAND PARKWAY<br />
05/01/2012<br />
RICE LAKE, WI 54868<br />
04/30/2014<br />
MARRIAGE AND FAMILY HEALTH<br />
SERVICES, LTD.<br />
Tier 1<br />
132 W COLUMBIA STREET<br />
05/01/2012<br />
CHIPPEWA FALLS, WI 54729<br />
04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 180 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2144<br />
MARRIAGE AND FAMILY HEALTH SERVICES, LTD.<br />
THOMAS E JOHNSTON<br />
612 E. WORDEN AVENUE<br />
LADYSMITH, WI 54848<br />
County: Rusk<br />
ladysmithmikan@centurytel.net<br />
Phone: (715) 532-0632<br />
Fax: (715) 532-4999<br />
Surveyor: Bradley Jahr<br />
Services<br />
05/01/1999<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2145<br />
MARRIAGE AND FAMILY HEALTH SERVICES, LTD.<br />
THOMAS E JOHNSTON<br />
250 BUFFALO STREET<br />
MONDOVI, WI 54755<br />
County: Buffalo<br />
mondovimikan@frontiernet.net<br />
Phone: (715) 926-5886<br />
Fax: (715) 926-5982<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1999<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2623<br />
MARRIAGE AND FAMILY HEALTH SERVICES, LTD.<br />
THOMAS JOHNSTON, PHD<br />
501 S CHERRY AVENUE, #5<br />
MARSHFIELD, WI 54449<br />
County: Wood<br />
MFHSEC@sbcglobal.net<br />
Phone: (715) 486-8302<br />
Fax: (715) 486-9253<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2006<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
MARRIAGE & FAMILY HLTH<br />
SVS-PITTSVILLE SCHOOL<br />
5407 1ST AVENUE<br />
PITTSVILLE, WI 54466<br />
05/01/2012 04/30/2014<br />
Tier 1<br />
06/11/2012<br />
12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 181 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2859<br />
MARRIAGE AND FAMILY HEALTH SERVICES, LTD.<br />
THOMAS E JOHNSTON<br />
2910 ENLOE STREET UNIT 4<br />
HUDSON, WI 54016<br />
County: Sa<strong>in</strong>t Croix<br />
hudsonmikan@att.net<br />
Phone: (715) 381-5437<br />
Fax: (715) 381-5438<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/2009<br />
08/28/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2707<br />
MARRIAGE AND FAMILY HEALTH SERVICES, LTD<br />
SUE SUCKOW<br />
105 WEST AVENUE<br />
RICE LAKE, WI 54868<br />
County: Barron<br />
No Email Address Provided<br />
Phone: (715) 736-5437<br />
Fax: (715) 736-5438<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2007<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
NO BRANCH LOCATIONS<br />
08/28/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 01/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 182 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2203<br />
MARSHFIELD CLINIC - EAU CLAIRE RIVERVIEW<br />
CENTER PSYCHIATRY & BEHAVIORAL HEALTH<br />
SHERI THOMPSON<br />
1000 STARR AVENUE<br />
EAU CLAIRE, WI 54703<br />
County: Eau Claire<br />
thompson.sheri@marshfieldcl<strong>in</strong>ic.org<br />
Phone: (715) 858-4859<br />
Fax: (715) 858-4513<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/14/2000<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2325<br />
MARSHFIELD CLINIC - RICE LAKE<br />
SHERI THOMPSON<br />
LAKEWOOD CENTER, 1215 W KNAPP ST<br />
RICE LAKE, WI 54868<br />
County: Barron<br />
thompson.sheri@marshfieldcl<strong>in</strong>ic.org<br />
Phone: (715) 858-4859<br />
Fax: (715) 858-4513<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
MARSHFIELD CLINIC - CORNELL<br />
CENTER<br />
600 WOODSIDE DRIVE<br />
CORNELL, WI 54732<br />
MARSHFIELD CLINIC - EAU CLAIRE<br />
CENTER<br />
2116 CRAIG ROAD<br />
EAU CLAIRE, WI 54701<br />
MARSHFIELD CLINIC - LADYSMITH<br />
CENTER<br />
906 COLLEGE AVENUE, WEST<br />
LADYSMITH, WI 54848<br />
MARSHFIELD CLINIC - MENOMONIE<br />
CENTER<br />
3603 SCHNEIDER AVENUE<br />
MENOMONIE, WI 54751<br />
MARSHFIELD CLINIC - RICE LAKE<br />
CENTER<br />
1700 W STOUT STREET<br />
RICE LAKE, WI 54868<br />
Tier 1<br />
07/01/2011<br />
06/30/2013<br />
Tier 1<br />
07/01/2011<br />
06/30/2012<br />
Tier 1<br />
07/01/2011<br />
06/30/2013<br />
Tier 1<br />
07/01/2011<br />
06/30/2013<br />
Tier 1<br />
07/01/2011<br />
06/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/23/2000<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 183 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1566<br />
MARSHFIELD CLINIC DEPARTMENT OF<br />
PSYCHIATRY AND BEHAVIORAL HEALTH<br />
SANDRA BUMP<br />
1000 N OAK AVENUE<br />
MARSHFIELD, WI 54449<br />
County: Wood<br />
bump.s<strong>and</strong>ra@marshfieldcl<strong>in</strong>ic.org<br />
Phone: (715) 389-5744<br />
Fax: (715) 387-9025<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/1982<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
1572<br />
MARSHFIELD CLINIC MINOCQUA COUNSELING<br />
CENTER<br />
MIKE MEGNA<br />
9792 HIGHWAY 70, WEST<br />
MINOCQUA, WI 54548<br />
County: Oneida<br />
No Email Address Provided<br />
Phone: (715) 356-1793<br />
Fax: (715) 358-7863<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
MARSHFIELD CLINIC MOSINEE CENTER Tier 1<br />
390 ORBITING DRIVE<br />
12/01/2010<br />
MOSINEE, WI 54455<br />
11/30/2012<br />
MARSHFIELD CLINIC WAUSAU CENTER Tier 1<br />
2727 PLAZA DRIVE<br />
12/01/2010<br />
WAUSAU, WI 54401<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1999<br />
12/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
1573<br />
MATT TALBOT RECOVERY CENTER<br />
KATHY MURAWSKI<br />
2613 W. NORTH AVENUE<br />
MILWAUKEE, WI 53205<br />
County: Milwaukee<br />
Kathy@arobhc.com<br />
Phone: (414) 342-5474<br />
Fax: (414) 342-5476<br />
Surveyor: Demetrius Anderson<br />
Services<br />
MARSHFIELD CLINIC COUNSELING<br />
CENTER<br />
50 SHERRY AVENUE<br />
PARK FALLS, WI 54552<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Tier 1<br />
12/01/2010<br />
10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/07/1997<br />
03/01/2011<br />
02/28/2013<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
12/01/2010 10/31/2012<br />
12/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2011 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 184 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1371<br />
MAYO CLINIC FRANCISCAN HEALTH CARE<br />
COMMUNITY SUPPORT PROGRAM<br />
MARY OLSTAD-HANSON<br />
464 S. ST. JOSEPHS AVENUE<br />
ARCADIA, WI 54612<br />
County: Trempealeau<br />
Olstadhanson.Mary@mayo.edu<br />
Phone: (608) 323-7775<br />
Fax: (608) 323-2052<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1993<br />
02/01/2012<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Com Support Program w/Telehealth DHS 63<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1511<br />
MAYO CLINIC HEALTH SYSTEM - EAU CLAIRE<br />
HOSPITAL, INC<br />
KARLENE PHILLIPS<br />
1221 WHIPPLE STREET<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
No Email Address Provided<br />
Phone: (715) 838-3274<br />
Fax: (715) 838-3649<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1981<br />
12/01/2010<br />
11/30/2012<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
1369<br />
MAYO CLINIC HEALTH SYSTEM - FRANCISCAN<br />
MEDICAL CENTER INC.- VILLA SUCCES<br />
MS LACIE ANTHONY<br />
121 S. PRAIRIE STREET<br />
PRAIRIE DU CHIEN, WI 53821<br />
County: Crawford<br />
Anthony.Lacie@mayo.edu<br />
Phone: (608) 326-8424<br />
Fax: (608) 326-8638<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2012 02/28/2013<br />
02/01/2012 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1987<br />
04/01/2012<br />
03/31/2013<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Prevention DHS 75.04<br />
CSAS-Residential Intoxication Monitor<strong>in</strong>g DHS 75.09<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2013<br />
04/01/2012 03/31/2013<br />
04/01/2012 03/31/2013<br />
04/01/2012 03/31/2013<br />
04/01/2012 03/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 185 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1360<br />
MAYO CLINIC HEALTH SYSTEM - FRANCISCAN<br />
MEDICAL CENTER, INC.- SCARSETH HOUSE<br />
JOSH COURT<br />
535 S. 17TH STREET<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
court.joshua@mayo.edu<br />
Phone: (608) 392-4542<br />
Fax: (608) 782-1811<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1991<br />
02/01/2012<br />
03/31/2013<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 03/31/2013<br />
02/01/2012 03/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 186 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1362<br />
MAYO CLINIC HEALTH SYSTEM - FRANCISCAN<br />
MEDICAL CENTER, INC.<br />
ROBERT HILARY<br />
212 S. 11TH STREET<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
Hillary.Robert@mayo.edu<br />
Phone: (608) 791-9555<br />
Fax: (608) 791-9793<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1977<br />
02/01/2012<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
MAYO CLINIC FRANCISCAN - GERARD<br />
HALL<br />
940 DIVISION STREET<br />
LA CROSSE, WI 54601<br />
MAYO CLINIC FRANCISCAN - HOLMEN<br />
CLINIC<br />
1303 MAIN STREET<br />
HOLMEN, WI 54636<br />
MAYO CLINIC FRANCISCAN - ONALASKA<br />
CLINIC<br />
191 THEATER ROAD<br />
ONALASKA, WI 54650<br />
MAYO CLINIC FRANCISCAN - PRAIRIE DU<br />
CHIEN CLINIC<br />
800 E BLACKHAWK AVENUE<br />
PRAIRIE DU CHIEN, WI 53821<br />
MAYO CLINIC FRANCISCAN - SCARSETH<br />
HOUSE<br />
535 S 17TH STREET<br />
LA CROSSE, WI 54601<br />
MAYO CLINIC FRANCISCAN - SIENA<br />
HALL<br />
608 S 11TH STREET<br />
LA CROSSE, WI 54601<br />
MAYO CLINIC FRANCISCAN - VILLA<br />
SUCCES<br />
121 PRAIRIE STREET<br />
PRAIRIE DU CHIEN, WI 53821<br />
MAYO CLINIC FRANCISCAN - WOMEN'S<br />
LAAR HOUSE<br />
1005 JACKSON STREET<br />
LA CROSSE, WI 54601<br />
MAYO CLINIC FRANCISCAN MEDICAL<br />
CENTER<br />
700 WEST AVENUE SOUTH<br />
LA CROSSE, WI 54601<br />
MAYO CLINIC FRANCISCAN MEDICAL<br />
CENTER<br />
800 WEST AVENUE SOUTH<br />
LA CROSSE, WI 54601<br />
Tier 1<br />
02/01/2012<br />
05/31/2013<br />
Tier 2<br />
02/01/2012<br />
05/31/2013<br />
Tier 2<br />
02/01/2012<br />
05/31/2013<br />
Tier 2<br />
02/01/2012<br />
05/31/2013<br />
Tier 1<br />
02/01/2012<br />
05/31/2013<br />
Tier 1<br />
02/01/2012<br />
05/31/2013<br />
Tier 1<br />
02/01/2012<br />
05/31/2013<br />
Tier 1<br />
02/01/2012<br />
05/31/2013<br />
Tier 2<br />
02/01/2012<br />
05/31/2013<br />
Tier 2<br />
02/01/2012<br />
05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 05/31/2013<br />
02/01/2012 05/31/2013<br />
02/01/2012 05/31/2013<br />
02/01/2012 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 187 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1363<br />
MAYO CLINIC HEALTH SYSTEM - FRANCISCAN<br />
MEDICAL CENTER, INC.<br />
LACIE ANTHONY<br />
464 SOUTH SAINT JOSEPH AVE<br />
ARCADIA, WI 54612<br />
County: Trempealeau<br />
Anthony.Lacie@mayo.edu<br />
Phone: (608) 323-7775<br />
Fax: (608) 323-2052<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1992<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1364<br />
MAYO CLINIC HEALTH SYSTEM - FRANCISCAN<br />
MEDICAL CENTER, INC.<br />
ROBERT HILLARY<br />
310 W. MAIN STREET<br />
SPARTA, WI 54656<br />
County: Monroe<br />
Hillary.Robert@mayo.edu<br />
Phone: (608) 269-4132<br />
Fax: (608) 269-9321<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1994<br />
02/01/2012<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1368<br />
MAYO CLINIC HEALTH SYSTEM - FRANCISCAN<br />
MEDICAL CENTER, INC.<br />
LACIE ANTHOY<br />
325 BUTTS AVENUE<br />
TOMAH, WI 54660<br />
County: Monroe<br />
Anthony.Lacie@mayo.edu<br />
Phone: (608) 372-5999<br />
Fax: (608) 372-6930<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
06/01/2012 05/31/2014<br />
06/01/2012 05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1995<br />
06/01/2012<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
02/01/2012 05/31/2013<br />
02/01/2012 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2013<br />
06/01/2012 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 188 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1370<br />
MAYO CLINIC HEALTH SYSTEM - FRANCISCAN<br />
MEDICAL CENTER, INC.<br />
NAN ANDERSON<br />
700 WEST AVENUE SOUTH<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
<strong>and</strong>erson.nanette@mayo.edu<br />
Phone: (608) 785-0940<br />
Fax: (608) 791-9736<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1977<br />
02/01/2012<br />
03/31/2013<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
1780<br />
MAYO CLINIC HEALTH SYSTEM - RED CEDAR<br />
DEBORAH LINDEMANN<br />
2321 STOUT ROAD<br />
MENOMONIE, WI 54751<br />
County: Dunn<br />
L<strong>in</strong>demann.deborah@mayo.edu<br />
Phone: (715) 233-7891<br />
Fax: (715) 233-7897<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1992<br />
05/23/2011<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1512<br />
MAYO CLINIC HEALTH SYSTEM EAU CLAIRE<br />
CINDY MING<br />
1221 WHIPPLE STREET<br />
EAU CLAIRE, WI 54702<br />
County: Eau Claire<br />
M<strong>in</strong>g.C<strong>in</strong>dy@mayo.edu<br />
Phone: (715) 838-5369<br />
Fax: (715) 838-3032<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2012 03/31/2013<br />
02/01/2012 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1981<br />
05/23/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
MAYO CLINIC HEALTH SYSTEM<br />
CHIPPEWA VALLEY<br />
611 FIRST AVE<br />
CHIPPEWA FALLS, WI 54729<br />
MAYO CLINIC HEALTH SYSTEM<br />
NORTHLAND<br />
331 S MAIN STREET, #H<br />
RICE LAKE, WI 54868<br />
MAYO CLINIC HEALTH<br />
SYSTEM-BLOOMER CLINIC<br />
1501 THOMPSON STREET<br />
BLOOMER, WI 54724<br />
05/23/2011 10/31/2012<br />
Tier 1<br />
05/23/2011<br />
12/31/2012<br />
Tier 1<br />
05/23/2011<br />
12/31/2012<br />
Tier 1<br />
01/01/2012<br />
12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/23/2011 12/31/2012<br />
05/23/2011 12/31/2012<br />
05/23/2011 12/31/2012<br />
05/23/2011 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 189 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2510<br />
MAYO CLINIC HEALTH SYSTEM-FRANCISAN<br />
MEDICAL CENTER, INC - WOMEN'S LAAR HOUSE<br />
PAMELA REYNOLDS<br />
1005 JACKSON STREET<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
reynolds.pamela@mayo.edu<br />
Phone: (608) 392-6147<br />
Fax: (608) 392-9511<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/19/2004<br />
04/01/2012<br />
03/31/2014<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
1580<br />
MCW DEPARTMENT OF PSYCHIATRY CLINICS AT<br />
TOSA<br />
JEFFREY G MILLER<br />
1155 N. MAYFAIR ROAD<br />
MILWAUKEE, WI 53226<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 955-8900<br />
Fax: (414) 955-6295<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1996<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2225<br />
MD THERAPY<br />
THOMAS (MIKE) DALE<br />
6815 W CAPITOL DRIVE, #208<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
mdtherapybh@aol.com<br />
Phone: (414) 466-3204<br />
Fax: (414) 466-3206<br />
Surveyor: Demetrius Anderson<br />
Services<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
MCW DPT PSYCH CLINICS @ COMM MEM<br />
MED COM<br />
W129 N7055 NORTHFIELD DRIVE, #301<br />
MENOMONEE FALLS, WI 53051<br />
Tier 2<br />
02/01/2011<br />
01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/05/2000<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2014<br />
06/01/2012 05/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 190 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1578<br />
MEDICAL AND COUNSELING ASSOCIATES<br />
ANN DAKE<br />
N5367 MAYFLOWER RD<br />
SHIOCTON, WI 54170<br />
County: Outagamie<br />
adake@chapsacademy.org<br />
Phone: (920) 986-3003<br />
Fax: (920) 986-3004<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1986<br />
02/01/2012<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Children 1 w/Telehealth DHS 40.11(2)(a)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2530<br />
MELONAS COUNSELING SERVICES, LLC<br />
IRENE MELONAS<br />
726 E SECOND STREET<br />
MERRILL, WI 54452<br />
County: L<strong>in</strong>coln<br />
melonascounsel<strong>in</strong>g@charter<strong>in</strong>ternet.com<br />
Phone: (715) 536-4440<br />
Fax: (715) 536-2736<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
MEDICAL & COUNSELING ASSOCIATES<br />
KAUKAUNA<br />
2416 CROOKS AVENUE<br />
KAUKAUNA, WI 54130<br />
MEDICAL AND COUNSELING<br />
ASSOCIATES<br />
300 N WOODS EDGE DR<br />
APPLETON, WI 54914<br />
Tier 1<br />
02/01/2012<br />
01/31/2013<br />
Tier 1<br />
02/01/2012<br />
01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2004<br />
01/01/2010<br />
06/30/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1577<br />
MEMORIAL HEALTH CENTER CLINICS-MEDFORD,<br />
BEHAVIORAL HEALTH SERVICES<br />
DOREEN ELDRED<br />
143 S. GIBSON STREET<br />
MEDFORD, WI 54451<br />
County: Taylor<br />
doreen.eldred@aspirus.org<br />
Phone: (715) 748-2121<br />
Fax: (715) 748-8197<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2012 01/31/2013<br />
02/01/2012 01/31/2013<br />
02/01/2012 01/31/2013<br />
02/01/2012 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1978<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
01/01/2010 06/30/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 191 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2228<br />
MENOMINEE COUNTY HEALTH & HUMAN<br />
SERVICES DEPARTMENT CSP<br />
RACHEL KIELBLOCK<br />
W3272 WOLF RIVER ROAD<br />
KESHENA, WI 54135<br />
County: Menom<strong>in</strong>ee<br />
No Email Address Provided<br />
Phone: (715) 799-3861<br />
Fax: (715) 799-3517<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1994<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1587<br />
MENOMINEE COUNTY HEALTH & HUMAN<br />
SERVICES DEPARTMENT<br />
BARBARA NELSON<br />
W3272 WOLF RIVER ROAD<br />
KESHENA, WI 54135<br />
County: Menom<strong>in</strong>ee<br />
barbexdir@co.menom<strong>in</strong>ee.wi.us<br />
Phone: (715) 799-3861<br />
Fax: (715) 799-3517<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1994<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Emergency Outpatent with Telehealth DHS 75.05<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 w/Telehealth DHS 34.3<br />
1588<br />
MENOMINEE TRIBAL CLINIC, BEHAVIORAL<br />
HEALTH SERVICES<br />
STEPHEN EISFELDER<br />
W3275 WOLF RIVER DRIVE<br />
KESHENA, WI 54135<br />
County: Menom<strong>in</strong>ee<br />
stevee@mtcl<strong>in</strong>ic.net<br />
Phone: (715) 799-5451<br />
Fax: (715) 799-3929<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/03/1993<br />
06/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2011 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 192 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1603<br />
MENTAL HEALTH RESOURCES<br />
SUSAN A BROWN PHD<br />
402 GAMMON PLACE, #290<br />
MADISON, WI 53719<br />
County: Dane<br />
DrsBrown@tds.net<br />
Phone: (608) 833-9770<br />
Fax: (608) 833-1197<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/1990<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1606<br />
MENTAL HEALTH SOLUTIONS, SC<br />
DAVID GOLDFOOT PHD<br />
7633 GANSER WAY, #204<br />
MADISON, WI 53719<br />
County: Dane<br />
mhs<strong>in</strong>fo@mhsolutions.com<br />
Phone: (608) 829-1800<br />
Fax: (608) 829-1885<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1995<br />
01/01/2012<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1613<br />
MERCY COUNSELING SERVICES<br />
TINA LECHNIR<br />
515 S. WASHBURN STREET, #104<br />
OSHKOSH, WI 54904<br />
County: W<strong>in</strong>nebago<br />
tlechnir@aff<strong>in</strong>ityhealth.org<br />
Phone: (920) 236-8570<br />
Fax: (920) 236-8591<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1995<br />
09/01/2012<br />
08/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 193 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1608<br />
MERCY MEDICAL CENTER<br />
TINA LECHNIR<br />
500 S. OAKWOOD ROAD<br />
OSHKOSH, WI 54904<br />
County: W<strong>in</strong>nebago<br />
tlechnir@aff<strong>in</strong>ityhealth.org<br />
Phone: (920) 223-3400<br />
Fax: (920) 223-3404<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/1982<br />
09/01/2012<br />
08/31/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
1612<br />
MERCY OPTIONS - MERCY HEALTH SYSTEMS<br />
ANN BUNNELL<br />
1000 MINERAL POINT ROAD<br />
JANESVILLE, WI 53548<br />
County: Rock<br />
abunnell@mhsjvl.org<br />
Phone: (608) 756-6545<br />
Fax: (608) 756-6564<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1984<br />
07/01/2011<br />
06/30/2013<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
NO BRANCH LOCATIONS<br />
09/01/2012 08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 194 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1610<br />
MERCY OPTIONS BEHAVIORAL HEALTH CLINIC -<br />
JANESVILLE<br />
GREG WINKLER<br />
903 MINERAL POINT ROAD<br />
JANESVILLE, WI 53547<br />
County: Rock<br />
gw<strong>in</strong>kler@mhsjvl.org<br />
Phone: (608) 756-5555<br />
Fax: (608) 756-0174<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1993<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2403<br />
MERCY OPTIONS BEHAVIORAL HEALTH CLINIC -<br />
WALWORTH<br />
GREG WINKLER<br />
N2846 STATE ROAD 67<br />
WILLIAMS BAY, WI 53191<br />
County: Walworth<br />
gw<strong>in</strong>kler@mhsjvl.org<br />
Phone: (262) 245-5608<br />
Fax: (262) 245-5648<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
MERCY MALL CLINIC Tier 1<br />
1010 N WASHINGTON<br />
01/01/2012<br />
JANESVILLE, WI 53545<br />
12/31/2013<br />
MERCY BELOIT CLINIC Tier 2<br />
2825 PRAIRIE AVENUE<br />
01/01/2012<br />
BELOIT, WI 53511<br />
12/31/2013<br />
MERCY CLINIC NORTH Tier 1<br />
3400 DEERFIELD DRIVE<br />
08/10/2012<br />
JANESVILLE, WI 53546<br />
12/31/2013<br />
MERCY EAST CLINIC Tier 1<br />
3524 E MILWAUKEE STREET<br />
01/01/2012<br />
JANESVILLE, WI 53546<br />
12/31/2013<br />
MERCY EVANSVILLE CLINIC Tier 2<br />
300 UNION STREET<br />
01/01/2012<br />
EVANSVILLE, WI 53536<br />
12/31/2013<br />
MERCY OPTIONS BH CLINIC -<br />
WALWORTH<br />
Tier 1<br />
N2846 STATE ROAD 67<br />
01/01/2012<br />
WILLIAMS BAY, WI 53191<br />
12/31/2013<br />
MERCY OPTIONS-OUTPATIENT<br />
SERVICES<br />
Tier 1<br />
507 W MAIN ST<br />
01/01/2012<br />
WHITEWATER, WI 53190<br />
12/31/2013<br />
MERCY WEST CLINIC Tier 1<br />
1000 MINERAL POINT ROAD<br />
01/01/2012<br />
JANESVILLE, WI 53545<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/16/2002<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2010 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 195 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2741<br />
MERCY OPTIONS CHILD AND ADOLESCENT DAY<br />
TREATMENT<br />
JESSICA BENASH<br />
200 E COURT STREET<br />
JANESVILLE, WI 53545<br />
County: Rock<br />
jbenash@mhsjvl.org<br />
Phone: (608) 741-2117<br />
Fax: (608) 758-5761<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/2007<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 2 DHS 40.11(2)(b)<br />
1611<br />
MERCY OPTIONS OUTPATIENT SERVICES<br />
LISA USGAARD<br />
2825 PRAIRIE AVENUE<br />
BELOIT, WI 53511<br />
County: Rock<br />
lusgaard@mhsjvl.org<br />
Phone: (608) 362-7330<br />
Fax: (608) 756-0174<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1996<br />
01/01/2008<br />
12/31/2009<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1013<br />
MERITER HOSPITAL BEHAVIORAL SERVICES<br />
PROGRAM<br />
SUSAN JANTY<br />
202 S. PARK STREET<br />
MADISON, WI 53715<br />
County: Dane<br />
sjanty@meriter.com<br />
Phone: (608) 417-5346<br />
Fax: (608) 417-5334<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1984<br />
12/01/2010<br />
11/30/2012<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Medically Managed Inpatient Treatment DHS 75.10<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
NO BRANCH LOCATIONS<br />
01/01/2008 12/31/2009<br />
01/01/2008 12/31/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012<br />
12/01/2010 05/02/2011<br />
12/01/2010 05/02/2011<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 196 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1617<br />
MERITER-NEWSTART OUTPATIENT CLINIC<br />
MICHAEL GERST<br />
1015 GAMMON LANE<br />
MADISON, WI 53719<br />
County: Dane<br />
No Email Address Provided<br />
Phone: (608) 417-8144<br />
Fax: (608) 274-3457<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1988<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1668<br />
MERITER'S CHILD & ADOLESCENT PSYCHIATRIC<br />
HOSPITAL<br />
SUSAN JANTY<br />
8001 RAYMOND ROAD<br />
MADISON, WI 53719<br />
County: Dane<br />
SJanty@meriter.com<br />
Phone: (608) 417-5346<br />
Fax: (608) 417-5334<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1984<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 2 DHS 40.11(2)(b)<br />
1619<br />
META HOUSE, INC (SHOREWOOD CAMPUS) AKA<br />
META III<br />
CHRISTINE ULLSTRUP<br />
3924-26 N. MARYLAND AVENUE<br />
MILWAUKEE, WI 53211<br />
County: Milwaukee<br />
cullstrup@metahouse.org<br />
Phone: (414) 962-1200<br />
Fax: (414) 962-2305<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1995<br />
02/01/2011<br />
01/31/2013<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 197 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2022<br />
META HOUSE, INC (SOUTH CAMPUS) AKA<br />
RIVERWEST<br />
CHRISTINE ULLSTRUP<br />
2618 N. BREMEN STREET<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
mail@metahouse.org<br />
Phone: (414) 962-1200<br />
Fax: (414) 962-2305<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/20/1998<br />
02/01/2011<br />
01/31/2013<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
1620<br />
META HOUSE, INC. (NORTH CAMPUS)<br />
CHRISTINE ULLSTRUP<br />
2626 N. BREMEN STREET<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
cullstrup@metahouse.org<br />
Phone: (414) 962-1200<br />
Fax: (414) 962-2305<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1995<br />
08/01/2011<br />
07/31/2013<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
2172<br />
META HOUSE, INC.<br />
CHRISTINE ULLSTRUP<br />
2625 N WEIL STREET<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
cullstrup@metahouse.org<br />
Phone: (414) 962-1200<br />
Fax: (414) 962-2305<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/24/1999<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 198 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2444<br />
MI FAMILIA<br />
NICOLAN REYES<br />
2960 S. 13TH STREET<br />
MILWAUKEE, WI 53215<br />
County: Milwaukee<br />
mifamiliareyes@yahoo.com<br />
Phone: (414) 383-0755<br />
Fax: (414) 383-0757<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/16/2003<br />
05/01/2008<br />
04/30/2010<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1624<br />
MIDWEST CENTER FOR HUMAN<br />
SERVICES-MILWAUKEE, LLC<br />
JACK KAUFMAN<br />
817 N. MARSHALL STREET<br />
MILWAUKEE, WI 53202<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 224-0800<br />
Fax: (414) 224-0883<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1991<br />
12/01/2008<br />
11/30/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1625<br />
MIDWEST CENTER FOR PSYCHOTHERAPY AND<br />
SEX THERAPY<br />
PATRICIA MILES PATTERSON<br />
6300 UNIVERSITY AVENUE, #125<br />
MIDDLETON, WI 53562<br />
County: Dane<br />
patmp@<strong>in</strong>xpress.net<br />
Phone: (608) 237-8000<br />
Fax: (608) 237-8005<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2008 04/30/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1993<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
12/01/2008 11/30/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 199 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2900<br />
MIDWEST PSYCHOLOGICAL SERVICES<br />
BRADLEY NEVINS<br />
2501 HANLEY ROAD, #F<br />
HUDSON, WI 54016<br />
County: Sa<strong>in</strong>t Croix<br />
brad@midwestpsychologicalservices.com<br />
Phone: (715) 381-1980<br />
Fax: (715) 381-1906<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/11/2010<br />
03/11/2010<br />
02/28/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1621<br />
MID-WISCONSIN PSYCHOTHERAPY ASSOCIATES<br />
RICHARD HURLBUT<br />
100 BREMMER STREET<br />
STEVENS POINT, WI 54481<br />
County: Portage<br />
rwhurlbut@midwiscons<strong>in</strong>psychotherapy.com<br />
Phone: (715) 344-2016<br />
Fax: (715) 344-1715<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
MIDWEST PSYCHOLOGICAL SERVICES Tier 2<br />
230 S WASHINGTON STREET<br />
03/11/2010<br />
ST CROIX FALLS, WI 54024<br />
02/28/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/20/1998<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2475<br />
MILWAUKEE ACADEMY OUTPATIENT MENTAL<br />
HEALTH CLINIC<br />
DANA DORN<br />
9501 WATERTOWN PLANK ROAD<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
ddorn@cl<strong>in</strong>icarecorp.com<br />
Phone: (414) 257-3141<br />
Fax: (414) 257-3151<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/11/2010 02/28/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/10/2003<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 200 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1630<br />
MILWAUKEE CENTER FOR INDEPENDENCE CSP<br />
DANIELLE BIRDEAU<br />
1040 S 70TH STREET<br />
MILWAUKEE, WI 53214<br />
County: Milwaukee<br />
DBirdeau@mcfi.net<br />
Phone: (414) 476-9675<br />
Fax: (414) 615-0627<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/1995<br />
08/01/2009<br />
07/31/2011<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1640<br />
MILWAUKEE COUNTY BEHAVIORAL HEALTH<br />
DIVISION - SOUTHSIDE CSP<br />
LOIS GILDERSLEEVE<br />
1201 WEST MITCHELL STREET<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
lgildersleeve@milwcnty.com<br />
Phone: (414) 454-4444<br />
Fax: (414) 649-4639<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1990<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1634<br />
MILWAUKEE COUNTY BEHAVIORAL HEALTH<br />
DIVISION MOBILE URGENT TREATMENT TEAM<br />
CHRIS MORANO<br />
9201 WATERTOWN PLANK ROAD<br />
MILWAUKEE, WI 53226<br />
County: Milwaukee<br />
cmorano@wrapmilw.org<br />
Phone: (414) 257-7621<br />
Fax: (414) 257-8126<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2009 07/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1996<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 201 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1632<br />
MILWAUKEE COUNTY BEHAVIORAL HEALTH<br />
DIVISION<br />
JIM KUBICEK<br />
9455 WATERTOWN PLANK ROAD<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
Jkubicek@milwcnty.com<br />
Phone: (414) 257-7482<br />
Fax: (414) 257-7019<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/01/1977<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
1637<br />
MILWAUKEE COUNTY BEHAVIORAL HEALTH<br />
DIVISION-DOWNTOWN CSP<br />
KRISTA DOUGHTY<br />
734 N. 4TH STREET, #300<br />
MILWAUKEE, WI 53203<br />
County: Milwaukee<br />
KDoughty@milwcnty.com<br />
Phone: (414) 289-6090<br />
Fax: (414) 226-4184<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1990<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1962<br />
MILWAUKEE HEALTH SERVICE SYSTEMS D/B/A<br />
VALLEY HEALTH SERVICES<br />
JANE WILLIQUETTE<br />
3301B NORTH BALLARD RD<br />
APPLETON, WI 54911<br />
County: Outagamie<br />
Jwilliquette@crchealth.com<br />
Phone: (920) 733-4443<br />
Fax: (920) 733-4796<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/09/1990<br />
07/01/2012<br />
06/30/2013<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2013<br />
07/01/2012 06/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 202 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1643<br />
MILWAUKEE HEALTH SERVICE SYSTEMS DBA<br />
RIVER'S SHORE CLINIC<br />
CARI PFANNERSTILL<br />
3707 N RICHARDS STREET<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
cpfannerstill@crchealth.com<br />
Phone: (414) 967-7006<br />
Fax: (414) 967-7020<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1986<br />
08/01/2012<br />
07/31/2014<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1644<br />
MILWAUKEE HEALTH SERVICE SYSTEMS II<br />
DANIEL LANGENWALTER<br />
4800 S. 10TH STREET, #1<br />
MILWAUKEE, WI 53221<br />
County: Milwaukee<br />
dlangenwalter@crchealth.com<br />
Phone: (414) 744-5370<br />
Fax: (414) 744-9052<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1995<br />
08/01/2011<br />
07/31/2013<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2408<br />
MILWAUKEE HEALTH SERVICES SYSTEMS D/B/A<br />
WAUSAU HEALTH SERVICES<br />
DEB PISKOTY<br />
209 W. WASHINGTON STREET<br />
WAUSAU, WI 54403<br />
County: Marathon<br />
No Email Address Provided<br />
Phone: (715) 845-3637<br />
Fax: (715) 845-1977<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/13/2003<br />
11/01/2011<br />
10/31/2012<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/08/2012 10/31/2012<br />
11/01/2011 10/31/2012<br />
11/01/2011 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 203 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1642<br />
MILWAUKEE HEALTH SERVICES, INC. DBA<br />
BEHAVIORAL HEALTH SERVICES CENTER<br />
YVONNE BELL-GOODEN<br />
8200 W SILVER SPRING DRIVE<br />
MILWAUKEE, WI 53218<br />
County: Milwaukee<br />
ybell-gooden@mhsi.org<br />
Phone: (414) 760-3900<br />
Fax: (414) 760-3917<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/1994<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1645<br />
MILWAUKEE MENTAL HEALTH ASSOCIATES<br />
COMMUNITY SUPPORT PROGRAM<br />
ARTHUR NOBLE<br />
4957 W. FOND DU LAC AVENUE<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
art.noble@mmhabh.org<br />
Phone: (414) 873-1960<br />
Fax: (414) 873-4990<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
MARTIN LUTHER KING-HERITAGE<br />
HEALTH CENTER<br />
2555 N MARTIN LUTHER KING JR DRIVE<br />
MILWAUKEE, WI 53212<br />
Tier 1<br />
05/01/2011<br />
04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/18/1997<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2739<br />
MILWAUKEE MENTAL HEALTH ASSOCIATES<br />
ARTHUR NOBLE<br />
3975 NORTH 68TH STREET #201<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
art.noble@mmhabh.org<br />
Phone: (414) 873-1960<br />
Fax: (414) 873-4990<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/20/2007<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 204 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2789<br />
MILWAUKEE MENTAL HEALTH ASSOCIATES<br />
ARTHUR NOBLE<br />
821 W STATE STREET, RM 205<br />
MILWAUKEE, WI 53233<br />
County: Milwaukee<br />
artnoble@ameritech.net<br />
Phone: (414) 873-4960<br />
Fax: (414) 873-4990<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/20/2008<br />
07/01/2009<br />
06/30/2010<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1652<br />
MILWAUKEE WELLNESS CLINIC, INC.<br />
WENDY WALSH<br />
4465 N OAKLAND AVENUE<br />
MILWAUKEE, WI 53211<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 961-1440<br />
Fax: No Number Provided<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1978<br />
11/01/2009<br />
10/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2891<br />
MINDSTAR COUNSELING, LLC<br />
STARLETTE PATTERSON<br />
8532 W CAPITOL DRIVE, #200<br />
MILWAUKEE, WI 53222<br />
County: Milwaukee<br />
m<strong>in</strong>dstarcounsel<strong>in</strong>g@yahoo.com<br />
Phone: (414) 435-1115<br />
Fax: (414) 435-0543<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2009 06/30/2010<br />
07/01/2009 06/30/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2009<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
11/01/2009 10/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 205 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1216<br />
MINISTRY BEHAVIORAL HEALTH<br />
LAURIE ROBERTS<br />
201 PRENTICE STREET NORTH<br />
STEVENS POINT, WI 54481<br />
County: Portage<br />
No Email Address Provided<br />
Phone: (715) 345-0711<br />
Fax: (715) 345-0223<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1990<br />
07/01/2011<br />
06/30/2013<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
1217<br />
MINISTRY BEHAVIORAL HEALTH<br />
LAURIE ROBERTS<br />
209 PRENTICE STREET NORTH<br />
STEVENS POINT, WI 54481<br />
County: Portage<br />
No Email Address Provided<br />
Phone: (715) 344-4611<br />
Fax: (715) 344-8127<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1991<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2645<br />
MINISTRY BEHAVIORAL HEALTH<br />
TERESA TAYLOR<br />
190 GRAND SEASONS DRIVE<br />
WAUPACA, WI 54981<br />
County: Waupaca<br />
terri.taylor@m<strong>in</strong>istryhealth.org<br />
Phone: (715) 258-8459<br />
Fax: (715) 258-0878<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2006<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 206 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1796<br />
MINISTRY MEDICAL GROUP-PSYCHIATRY<br />
DEPARTMENT<br />
LINDA MASSOPUST<br />
3398 E. MARIA DRIVE<br />
STEVENS POINT, WI 54481<br />
County: Portage<br />
l<strong>in</strong>da.massopust@m<strong>in</strong>istryhealth.org<br />
Phone: (715) 341-7441<br />
Fax: (715) 343-2088<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/1983<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1915<br />
MONROE CLINIC BEHAVIORAL HEALTH<br />
TODD NOGGLE<br />
515 - 22ND AVENUE<br />
MONROE, WI 53566<br />
County: Green<br />
todd.noggle@monroecl<strong>in</strong>ic.org<br />
Phone: (608) 324-2321<br />
Fax: (608) 324-2102<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1981<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2282<br />
MONROE COUNTY COMMUNITY SUPPORT<br />
PROGRAM<br />
SUSAN RETTLER<br />
14301 HWY B, COMM SVS CTR A-19<br />
SPARTA, WI 54656<br />
County: Monroe<br />
srettler@co.monroe.wi.us<br />
Phone: (608) 269-8630<br />
Fax: (608) 269-8935<br />
Surveyor: Polly Wong<br />
Services<br />
NEW GLARUS BRANCH OF MONROE<br />
CLINIC<br />
1800 - 2ND ST<br />
NEW GLARUS, WI 53574<br />
01/01/2012 12/31/2013<br />
Tier 1<br />
08/01/2012<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1999<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 207 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1654<br />
MONROE COUNTY DEPARTMENT OF HUMAN<br />
SERVICES<br />
SUSAN RETTLER<br />
14301 HWY B, COMM SVS CTR A-19<br />
SPARTA, WI 54656<br />
County: Monroe<br />
srettler@co.monroe.wi.us<br />
Phone: (608) 269-8630<br />
Fax: (608) 269-8935<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1975<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2613<br />
MOORE AND ASSOCIATES/BIRDS OF A FEATHER,<br />
INC.<br />
TONY MOORE<br />
6530 SHERIDAN ROAD, #3<br />
KENOSHA, WI 53143<br />
County: Kenosha<br />
Tmoore@moore<strong>and</strong>associates.biz<br />
Phone: (262) 605-1444<br />
Fax: (262) 605-1404<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/14/2005<br />
04/01/2012<br />
09/30/2013<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1917<br />
MOORING PROGRAMS, INC.<br />
JAMIE LOEHNIS<br />
607 W. SEVENTH STREET<br />
APPLETON, WI 54911<br />
County: Outagamie<br />
Jamie@moor<strong>in</strong>gcasa.com<br />
Phone: (920) 739-3235<br />
Fax: (920) 731-4796<br />
Surveyor: Frank Bellaire<br />
Services<br />
MOORE AND ASSOC, INC/HARVEST<br />
CONSULTING<br />
2405 NORTHWESTERN AVENUE, #105<br />
RACINE, WI 53404<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Tier 1<br />
04/01/2012<br />
09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/08/1991<br />
07/01/2012<br />
06/30/2014<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Residential Intoxication Monitor<strong>in</strong>g DHS 75.09<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
04/01/2012 09/30/2013<br />
04/01/2012 09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 208 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1794<br />
MWCCA BEHAVIORAL HEALTH CLINIC<br />
LATRICE BUCK HOGAN<br />
728 NORTH JAMES LOVELL ST<br />
MILWAUKEE, WI 53203<br />
County: Milwaukee<br />
latricebuck@aol.com<br />
Phone: (414) 449-4777<br />
Fax: (414) 449-4774<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/1988<br />
07/01/2012<br />
06/30/2014<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2576<br />
MY HOME, YOUR HOME, INC.<br />
JAY PELDO<br />
6200 W. CENTER STREET<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
jaypeldo@myhomeyourhome.org<br />
Phone: (414) 874-2560<br />
Fax: (414) 874-2565<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/22/2005<br />
03/01/2009<br />
02/28/2011<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2933<br />
NATUREWORKS LEARNING CENTER, LLC<br />
DANIEL L. HUBER, PHD<br />
635 OLD COUNTY ROAD PP<br />
SHEBOYGAN FALLS, WI 53085<br />
County: Sheboygan<br />
natureworkslearn<strong>in</strong>gcenter@gmail.com<br />
Phone: (414) 587-6706<br />
Fax: No Number Provided<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2011<br />
02/01/2011<br />
01/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
03/01/2009 02/28/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2011 01/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 209 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2913<br />
NEERAJ AGRAWAL CLINIC, LTD<br />
NEERAJ AAGRAWAL<br />
7332 W STATE STREET, LL<br />
WAUWATOSA, WI 53213<br />
County: Milwaukee<br />
nacl<strong>in</strong>ic@neerajagrawal.com<br />
Phone: (262) 352-1845<br />
Fax: (262) 252-4874<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/18/2010<br />
06/01/2012<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1656<br />
NETT-WORK FAMILY COUNSELING, LLC<br />
CHRISTINE L. NETT<br />
2801 CALUMET DRIVE<br />
SHEBOYGAN, WI 53083<br />
County: Sheboygan<br />
office@nett-workfamilycounsel<strong>in</strong>g.org<br />
Phone: (920) 451-6908<br />
Fax: (920) 458-6439<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NEERAJ AGRAWAL CLINIC, LTD Tier 1<br />
1001 W GLEN OAKS LANE, #208<br />
06/01/2012<br />
MEQUON, WI 53092<br />
05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/27/1998<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2930<br />
NEW CHOICES, LLC<br />
LEOLA WILLIAMS<br />
3565 NORTH MARTIN LUTHER KING DR<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
leola_wllms@newchoicesllc.net<br />
Phone: (414) 444-8445<br />
Fax: (414) 444-8432<br />
Surveyor: Demetrius Anderson<br />
Services<br />
06/01/2012 05/31/2013<br />
NETT-WORK FAMILY COUNSELING LLC Tier 1<br />
1403 MILWAUKEE DR<br />
03/01/2012<br />
NEW HOLSTEIN, WI 53061<br />
02/28/2014<br />
NETT-WORK FAMILY COUNSELING LLC Tier 1<br />
621 E MILL ST<br />
03/01/2012<br />
PLYMOUTH, WI 53073<br />
02/28/2014<br />
NETT-WORK FAMILY COUNSELING LLC Tier 1<br />
1011 - 10TH STREET #1<br />
03/01/2012<br />
MANITOWOC, WI 54220<br />
02/28/2014<br />
NETT-WORK FAMILY COUNSELING, LLC Tier 2<br />
3321 SOUTH 12TH ST<br />
03/01/2012<br />
SHEBOYGAN, WI 53081<br />
02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/14/2010<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 210 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1660<br />
NEW CONCEPT SELF DEVELOPMENT CENTER,<br />
INC.<br />
VANESSA KEY<br />
4828 W. FOND DU LAC AVENUE<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
vanessakey@ncsdc-<strong>in</strong>c.org<br />
Phone: (414) 444-1952<br />
Fax: (414) 444-5557<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/1977<br />
09/01/2009<br />
07/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1662<br />
NEW DIRECTIONS COUNSELING CENTER, LLC<br />
DIANE DICKINSON<br />
5541 HWY 10 EAST, SUITE B<br />
STEVENS POINT, WI 54482<br />
County: Portage<br />
diane@newdirectionscc.com<br />
Phone: (715) 345-9690<br />
Fax: (715) 345-2938<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/16/1996<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Intervention DHS 75.16<br />
2698<br />
NEW HOPE COUNSELING CENTER OF<br />
WISCONSIN, INC.<br />
KRISTIN LAWNICZAK<br />
3311 S. PACKERLAND DR., STE A #3<br />
DE PERE, WI 54115<br />
County: Brown<br />
Kmlawniczak@yahoo.com<br />
Phone: (920) 338-0100<br />
Fax: (920) 338-0103<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2009 07/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2006<br />
09/01/2011<br />
12/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
06/01/2012 05/31/2014<br />
06/01/2012 05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2011 12/31/2011
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 211 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1663<br />
NEW HORIZONS NORTH-COMMUNITY SUPPORT<br />
PROGRAM<br />
VALERIE LEVNO<br />
324 W. BAYFIELD STREET<br />
WASHBURN, WI 54891<br />
County: Bayfield<br />
vlevno@nhnorth.com<br />
Phone: (715) 373-5505<br />
Fax: (715) 373-2203<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1991<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1664<br />
NEW HORIZONS NORTH-COMMUNITY SUPPORT<br />
PROGRAM<br />
ANDREW MACGREGOR<br />
514 W MAIN STREET<br />
ASHLAND, WI 54806<br />
County: Ashl<strong>and</strong><br />
amacgregor@nhnorth.com<br />
Phone: (715) 682-7171<br />
Fax: (715) 682-7176<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/13/1991<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2962<br />
NEW LEAF THERAPIES LLC<br />
LYNN DELAHAN<br />
4465 N OAKLAND AVE STE 400 D<br />
SHOREWOOD, WI 53211<br />
County: Milwaukee<br />
newleaftherapiesllc@gmail.com<br />
Phone: (414) 332-2227<br />
Fax: (414) 332-2228<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2012<br />
03/01/2012<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2012 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 212 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1665<br />
NEW LIFE RESOURCES, INC.<br />
DANIEL GREEN<br />
20700 WATERTOWN ROAD, #102<br />
WAUKESHA, WI 53186<br />
County: Waukesha<br />
drgreen@tls.net<br />
Phone: (262) 782-1474<br />
Fax: (262) 782-1441<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/1988<br />
06/01/2010<br />
05/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1669<br />
NEW WELLNESS ASSOCIATES, INC.<br />
JOANN BERKEN<br />
2733 S. RIDGE ROAD<br />
GREEN BAY, WI 54304<br />
County: Brown<br />
joannberk@yahoo.com<br />
Phone: (920) 497-6200<br />
Fax: (920) 497-3135<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1993<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2470<br />
NOO JII MOO WII GA MIEG (LAC COURTE<br />
OREILLES HALFWAY HOUSE)<br />
DOROTHY CRUST<br />
12929 W HAWKINS ROAD<br />
HAYWARD, WI 54843<br />
County: Sawyer<br />
lcohwh@jrecoop.com<br />
Phone: (715) 634-5841<br />
Fax: (715) 634-1059<br />
Surveyor: Bradley Jahr<br />
Services<br />
06/01/2010 05/31/2012<br />
NEW WELLNESS ASSOCIATES INC Tier 1<br />
2420 CROOKS AVENUE<br />
06/01/2012<br />
KAUKAUNA, WI 54130<br />
05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/18/2003<br />
07/01/2011<br />
06/30/2013<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
06/01/2012 05/31/2014<br />
06/01/2012 05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011 06/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 213 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1673<br />
NORRIS ADOLESCENT CENTER<br />
BILL WILKE<br />
W247 S10395 CENTER DRIVE<br />
MUKWONAGO, WI 53149<br />
County: Waukesha<br />
www.norriscenter.org<br />
Phone: (262) 662-5900<br />
Fax: (262) 662-5688<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1995<br />
03/01/2010<br />
02/29/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1674<br />
NORTH BAY LODGE<br />
BRUCE NICHOLAS<br />
3602 MEMORIAL DRIVE<br />
MADISON, WI 53704<br />
County: Dane<br />
B.NicholasHH@gmail.com<br />
Phone: (608) 249-2600<br />
Fax: (608) 242-2600<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1984<br />
12/01/2010<br />
11/30/2012<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Transitional Residential DHS 75.14<br />
1675<br />
NORTH CENTRAL COUNSELING CENTER<br />
DEBRA KOLTIS<br />
136 W. BROADWAY<br />
MEDFORD, WI 54451<br />
County: Taylor<br />
northcentral@tds.net<br />
Phone: (715) 748-4535<br />
Fax: (715) 748-0267<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2010 02/29/2012<br />
03/01/2010 02/29/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1994<br />
06/01/2012<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
NORTH CENTRAL COUNSELING CENTER Tier 1<br />
1511 RAILROAD AVE, PO BOX 104<br />
06/01/2012<br />
PRENTICE, WI 54556<br />
05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 214 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2316<br />
NORTH CENTRAL COUNSELING SERVICES<br />
JOSEPH ROE & ASSOC D/B/A SHIRLEY LIMBERG<br />
SHIRLEY LIMBERG<br />
8618 HIGHWAY 51 NORTH<br />
MINOCQUA, WI 54548<br />
County: Oneida<br />
slimberg3150@charter.net<br />
Phone: (715) 356-6146<br />
Fax: (715) 358-9556<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/2000<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2298<br />
NORTH CENTRAL HEALTH CARE<br />
CENTER/LANGLADE HEALTH CARE CENTER CSP<br />
KEITH WOLF<br />
1225 LANGLADE ROAD<br />
ANTIGO, WI 54409<br />
County: Langlade<br />
kwolfe@norcen.org<br />
Phone: (715) 627-6694<br />
Fax: (715) 627-6645<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NCCS J ROE & ASSOC DBA SHIRLEY<br />
LIMBERG<br />
HIGHWAY 13 N<br />
PARK FALLS, WI 54552<br />
Tier 1<br />
04/01/2012<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1987<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1676<br />
NORTH CENTRAL HEALTH CARE<br />
CENTER/LANGLADE HEALTH CARE CENTER<br />
JIM HAHN<br />
1225 LANGLADE ROAD<br />
ANTIGO, WI 54409<br />
County: Langlade<br />
jhahn@norcen.org<br />
Phone: (715) 627-6694<br />
Fax: (715) 627-6645<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1987<br />
06/01/2009<br />
05/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
06/01/2011 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/28/2009 02/28/2011<br />
10/28/2009 02/28/2011<br />
06/01/2009 02/28/2011<br />
10/28/2009 02/28/2011<br />
06/01/2009 05/31/2011<br />
06/01/2009 10/27/2009
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 215 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2562<br />
NORTH CENTRAL HEALTH CARE FACILITIES<br />
COMPREHENSIVE COMMUNITY SERVICES<br />
ERICA HUFFMAN<br />
1100 LAKEVIEW DRIVE<br />
WAUSAU, WI 54403<br />
County: Marathon<br />
ehuffman@norcen.org<br />
Phone: (715) 848-4322<br />
Fax: (715) 841-5146<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/2004<br />
01/01/2011<br />
12/31/2012<br />
Comprehensive Community Services (CCS) DHS 36<br />
2297<br />
NORTH CENTRAL HEALTH CARE FACILITIES CSP<br />
EAST & STURGEON POINT<br />
KEN WOLFE<br />
506 N. SIXTH STREET<br />
WAUSAU, WI 54403<br />
County: Marathon<br />
kwolfe@norcen.org<br />
Phone: (715) 843-6120<br />
Fax: (715) 848-5460<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1678<br />
NORTH CENTRAL HEALTH CARE FACILITIES<br />
LINCOLN HEALTH CARE CENTER CSP<br />
KEN WOLFE<br />
607 N. SALES STREET SUITE 309<br />
MERRILL, WI 54452<br />
County: L<strong>in</strong>coln<br />
kwolfe@norcen.org<br />
Phone: (715) 536-9482<br />
Fax: (715) 539-2972<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1987<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2011 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 216 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1679<br />
NORTH CENTRAL HEALTH CARE FACILITIES<br />
LINCOLN HEALTH CARE CENTER<br />
MARGARET PARSONS<br />
607 N. SALES STREET<br />
MERRILL, WI 54452<br />
County: L<strong>in</strong>coln<br />
mparsons@norcen.org<br />
Phone: (715) 536-9482<br />
Fax: (715) 539-2972<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1987<br />
06/01/2009<br />
05/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1677<br />
NORTH CENTRAL HEALTH CARE FACILITIES<br />
AEKTA DASSOW<br />
1100 LAKE VIEW DRIVE<br />
WAUSAU, WI 54403<br />
County: Marathon<br />
adassow@norcen.org<br />
Phone: (715) 848-4600<br />
Fax: (715) 845-6050<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
10/28/2009 02/28/2011<br />
10/28/2009 02/28/2011<br />
06/01/2009 02/28/2011<br />
10/28/2009 02/28/2011<br />
06/01/2009 05/31/2011<br />
06/01/2009 10/27/2009<br />
LANGLADE HEALTH CENTER Tier 2<br />
1225 LANGLADE ROAD<br />
03/01/2011<br />
ANTIGO, WI 54409<br />
02/28/2013<br />
LINCOLN HEALTH CARE CENTER Tier 2<br />
607 N SALES STREET, #309<br />
03/01/2011<br />
MERRILL, WI 54452<br />
02/28/2013<br />
LINCOLN HEALTH CARE<br />
CENTER-TOMAHAWK<br />
Tier 2<br />
310 W WISCONSIN PO BOX 411<br />
03/01/2011<br />
TOMAHAWK, WI 54487<br />
02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 217 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1681<br />
NORTH CENTRAL HEALTH CARE LINCOLN<br />
HEALTHCARE CENTER<br />
MARGARET A. PARSONS<br />
310 W. WISCONSIN AVENUE<br />
TOMAHAWK, WI 54487<br />
County: L<strong>in</strong>coln<br />
mparsons@norcen.org<br />
Phone: (715) 453-5381<br />
Fax: (715) 539-2972<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1992<br />
03/01/2009<br />
02/28/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1682<br />
NORTH SHORE CENTER, L.L.C.<br />
DR RAYMOND A GALLOPE<br />
10303 N. PT. WASHINGTON RD., #203<br />
MEQUON, WI 53092<br />
County: Ozaukee<br />
No Email Address Provided<br />
Phone: (262) 241-5955<br />
Fax: (262) 241-5926<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/19/1989<br />
07/01/2008<br />
06/30/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1683<br />
NORTH SHORE PSYCHOTHERAPY ASSOCIATES<br />
DANIELA JARAMILLO<br />
5800 N BAYSHORE DRIVE #A250<br />
GLENDALE, WI 53217<br />
County: Milwaukee<br />
djaramida@tds.net<br />
Phone: (414) 962-6764<br />
Fax: (414) 962-6765<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/28/2009 02/28/2011<br />
10/28/2009 02/28/2011<br />
03/01/2009 02/28/2011<br />
10/28/2009 02/28/2011<br />
03/01/2009 10/27/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1980<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
07/01/2008 06/30/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2010 09/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 218 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2685<br />
NORTHERN CROSSING BEHAVIORAL HEALTH<br />
SERVICES, LLC<br />
FRED JONES<br />
5303 W NORTH AVENUE<br />
MILWAUKEE, WI 53208<br />
County: Milwaukee<br />
northerncross<strong>in</strong>gbh@gmail.com<br />
Phone: (414) 445-0997<br />
Fax: (414) 445-0989<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/2006<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2878<br />
NORTHERN HEALTH CENTERS INC. NICOLET<br />
MEDICAL & DENTAL CLINIC<br />
JODI MARSH<br />
15397 HIGHWAY 32<br />
LAKEWOOD, WI 54138<br />
County: Oconto<br />
No Email Address Provided<br />
Phone: (715) 276-6321<br />
Fax: (715) 276-1428<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/24/2009<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2262<br />
NORTHLAND COMMUNITY SERVICES COMMUNITY<br />
SUPPORT PROGRAM<br />
DR JON MATTHEW<br />
161 SPRING STREET<br />
WESTFIELD, WI 53964<br />
County: Marquette<br />
ncs@maq.net<br />
Phone: (608) 296-2139<br />
Fax: (608) 296-1590<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1983<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 219 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2330<br />
NORTHLAND COMMUNITY SERVICES COMMUNITY<br />
SUPPORT PROGRAM<br />
CAROL LUND<br />
10270 OLKER ROAD<br />
HAYWARD, WI 54843<br />
County: Sawyer<br />
northl<strong>and</strong>csp@centurytel.net<br />
Phone: (715) 634-2522<br />
Fax: (715) 634-2533<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/2001<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1693<br />
NORTHLAND COMMUNITY SERVICES<br />
DR JON MATTHEW<br />
161 SPRING STREET<br />
WESTFIELD, WI 53964<br />
County: Marquette<br />
ncs@maq.net<br />
Phone: (608) 296-2139<br />
Fax: (608) 296-1590<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1983<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2213<br />
NORTHLAND COUNSELING SERVICES, LTD.<br />
CAROL LUND<br />
10752 BEAL STREET<br />
HAYWARD, WI 54843<br />
County: Sawyer<br />
northl<strong>and</strong>006@centurytel.net<br />
Phone: (715) 634-0222<br />
Fax: (715) 634-1722<br />
Surveyor: Bradley Jahr<br />
Services<br />
09/01/2010 08/31/2012<br />
NORTHLAND COMMUNITY SERVICES Tier 1<br />
139 S MAIN, PO BOX 1178<br />
11/01/2011<br />
ADAMS, WI 53910<br />
10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/03/2000<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NORTHLAND COUNSELING SERVICES<br />
LTD<br />
16096 US HWY 63<br />
HAYWARD, WI 54843<br />
NORTHLAND COUNSELING SERVICES<br />
LTD<br />
10270 OKLER ROAD<br />
HAYWARD, WI 54843<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
Tier 1<br />
04/12/2012<br />
03/31/2014<br />
Tier 1<br />
04/01/2012<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 220 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2361<br />
NORTHLAND COUNSELING SERVICES<br />
JEREMY KOEHL<br />
21 W OMAHA STREET<br />
WASHBURN, WI 54891<br />
County: Bayfield<br />
northl<strong>and</strong>006@centurytel.net<br />
Phone: (715) 373-0160<br />
Fax: (715) 373-0162<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/2001<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1695<br />
NORTHSHORE CLINIC & CONSULTANTS, INC.<br />
JOY MYERS<br />
W62 N248 WASHINGTON AVE., #207<br />
CEDARBURG, WI 53012<br />
County: Ozaukee<br />
joymyersnsc@yahoo.com<br />
Phone: (262) 375-1116<br />
Fax: (262) 375-1071<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NORTHLAND COUNSELING SERVICES Tier 1<br />
611 E WALL STREET<br />
07/01/2012<br />
EAGLE RIVER, WI 54521<br />
06/30/2014<br />
NORTHLAND COUNSELING SERVICES Tier 1<br />
1619 WEST THIRD STREET<br />
07/01/2012<br />
ASHLAND, WI 54806<br />
06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1987<br />
08/01/2012<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1699<br />
NORTHSHORE CLINIC OF SHEBOYGAN, INC.<br />
SUE BALOG<br />
615 S. 8TH STREET, #G20<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
nsc@northshorecl<strong>in</strong>ic.org<br />
Phone: (920) 457-8866<br />
Fax: (920) 457-8867<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
NORTHSHORE CLINIC & CONSULTANTS Tier 1<br />
207 E BUFFALO STREET, #510<br />
08/01/2012<br />
MILWAUKEE, WI 53202<br />
07/31/2013<br />
NORTHSHORE CLINIC & CONSULTANTS Tier 2<br />
2363 S 102ND STREET, #203<br />
08/01/2012<br />
WEST ALLIS, WI 53227<br />
07/31/2013<br />
NORTHSHORE CLINIC & CONSULTANTS,<br />
INC<br />
Tier 2<br />
2607 N GRANDVIEW BLVD, #104<br />
08/01/2012<br />
WAUKESHA, WI 53188<br />
07/31/2013<br />
NORTHSHORE CLINIC & CONSULTANTS,<br />
INC.<br />
Tier 2<br />
1615 BARTON AVENUE<br />
08/01/2012<br />
WEST BEND, WI 53090<br />
07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/1991<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2013<br />
08/01/2012 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 221 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1685<br />
NORTHSTAR COUNSELING CENTER<br />
BEN FARBMAN<br />
700 RAYOVAC DRIVE, #010<br />
MADISON, WI 53711<br />
County: Dane<br />
b_farbman@yahoo.com<br />
Phone: (608) 270-1960<br />
Fax: (608) 270-1965<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1991<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2254<br />
NORTHWEST COUNSELING AND GUIDANCE<br />
CLINIC<br />
ANN PARDUN<br />
203 UNITED WAY DRIVE<br />
FREDERIC, WI 54837<br />
County: Polk<br />
annp@nwcg.com<br />
Phone: (715) 327-4402<br />
Fax: (715) 327-8447<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/25/1999<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2924<br />
NORTHWEST DIRECTIONS - MENOMONIE<br />
MARC WIEHL<br />
402 TECHNOLOGY DRIVE EAST<br />
MENOMONIE, WI 54751<br />
County: Dunn<br />
nwdmenomonie@nwcgc.com<br />
Phone: (715) 450-5241<br />
Fax: (715) 235-4421<br />
Surveyor: Polly Wong<br />
Services<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
NORTHWEST PASSAGE 1 Tier 2<br />
7818 MOLINE RD, PO BOX 349<br />
02/01/2012<br />
WEBSTER, WI 54893<br />
01/31/2014<br />
NORTHWEST PASSAGE II Tier 1<br />
1661 HAMMS ROAD<br />
02/01/2012<br />
SPOONER, WI 54801<br />
01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/26/2010<br />
02/01/2012<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
NORTHWEST DIRECTIONS-BLACK RIVER<br />
FALLS<br />
Tier 1<br />
N6643 COUNTY ROAD A<br />
02/01/2012<br />
BLACK RIVER FALLS, WI 54615<br />
01/31/2013<br />
NORTHWEST DIRECTIONS-CHIPPEWA<br />
FALLS<br />
Tier 1<br />
705 BAY STREET, #2E<br />
02/01/2012<br />
CHIPPEWA FALLS, WI 54729<br />
01/31/2013<br />
NORTHWEST DIRECTIONS-RIVER FALLS Tier 1<br />
2860 WILLIAMS AVENUE<br />
02/01/2012<br />
RIVER FALLS, WI 54022<br />
01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 01/31/2013<br />
02/01/2012 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 222 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2943<br />
NORTHWEST DIRECTIONS - SIREN<br />
SARAH BUSCH<br />
7670 JOHNSON STREET<br />
SIREN, WI 54872<br />
County: Burnett<br />
nwdsiren@nwcgc.com<br />
Phone: (715) 349-2829<br />
Fax: (715) 349-2737<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/08/2011<br />
03/11/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
2908<br />
NORTHWEST DIRECTIONS - WISCONSIN RAPIDS<br />
ANN PARDUN<br />
110 - 24TH STREET SOUTH<br />
WISCONSIN RAPIDS, WI 54494<br />
County: Wood<br />
AnnP@nwcgc.com<br />
Phone: (715) 424-5051<br />
Fax: (715) 424-5720<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NORTHWEST DIRECTIONS - AMERY Tier 1<br />
1096 APPLE AVENUE<br />
03/11/2011<br />
AMERY, WI 54001<br />
01/31/2013<br />
NORTHWEST DIRECTIONS - SUPERIOR Tier 1<br />
1419 HILL AVENUE SUITE B<br />
03/11/2011<br />
SUPERIOR, WI 54880<br />
01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/13/2010<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
2195<br />
NORTHWEST JOURNEY - AMERY<br />
ANN PARDUN<br />
1096 APPLE AVENUE<br />
AMERY, WI 54001<br />
County: Polk<br />
annp@nwcgc.com<br />
Phone: (715) 268-5404<br />
Fax: (715) 268-6103<br />
Surveyor: Bradley Jahr<br />
Services<br />
03/11/2011 01/31/2013<br />
03/11/2011 01/31/2013<br />
NORTHWEST DIRECTIONS - STEVENS<br />
POINT<br />
Tier 1<br />
525 - 4TH AVENUE<br />
04/01/2011<br />
STEVENS POINT, WI 54481<br />
03/31/2013<br />
NORTHWEST DIRECTIONS - WAUPACA<br />
COUNTY<br />
Tier 1<br />
310 E MAIN STREET<br />
04/01/2011<br />
WEYAUWEGA, WI 54983<br />
03/31/2013<br />
NORTHWEST DIRECTIONS - WAUSAU Tier 1<br />
2805 EMERY DRIVE<br />
04/01/2011<br />
WAUSAU, WI 54401<br />
03/31/2013<br />
NORTHWEST DIRECTIONS GREEN BAY Tier 1<br />
123 SOUTH VAN BUREN STREET<br />
04/01/2011<br />
GREEN BAY, WI 54301<br />
03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/14/2000<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Children 1 w/Telehealth DHS 40.11(2)(a)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
06/16/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 223 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2655<br />
NORTHWEST JOURNEY - BLACK RIVER FALLS<br />
JEN STEINKE<br />
N6643 COUNTY ROAD A<br />
BLACK RIVER FALLS, WI 54615<br />
County: Jackson<br />
NWJBlackRiverFalls@nwcgc.com<br />
Phone: (715) 284-1100<br />
Fax: (715) 284-1145<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/2006<br />
02/01/2012<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Children 1 w/Telehealth DHS 40.11(2)(a)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2160<br />
NORTHWEST JOURNEY - GREEN BAY<br />
JENNIFER SOVEY-FAHEY<br />
123 S. VAN BUREN STREET<br />
GREEN BAY, WI 54301<br />
County: Brown<br />
nwjgreenbay@nwcgc.com<br />
Phone: (920) 437-4024<br />
Fax: (920) 437-4343<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1999<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Children 1 w/Telehealth DHS 40.11(2)(a)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2660<br />
NORTHWEST JOURNEY - MENOMONIE<br />
JUSTINE PETERSON<br />
402 TECHNOLOGY DRIVE EAST<br />
MENOMONIE, WI 54751<br />
County: Dunn<br />
just<strong>in</strong>ep@nwcgc.com<br />
Phone: (715) 235-4245<br />
Fax: (715) 235-4421<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2012 01/31/2013<br />
02/01/2012 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2006<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Children 1 w/Telehealth DHS 40.11(2)(a)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 224 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2909<br />
NORTHWEST JOURNEY - RIVER FALLS<br />
MELAINE MURRAY<br />
2860 WILLIAMS AVENUE<br />
RIVER FALLS, WI 54022<br />
County: Pierce<br />
mrml@nwcgc.com<br />
Phone: (715) 425-5110<br />
Fax: (715) 425-5120<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/28/2010<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Children 1 w/Telehealth DHS 40.11(2)(a)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2290<br />
NORTHWEST JOURNEY - SIREN<br />
RON DIFFEE<br />
7670 JOHNSON STREET<br />
SIREN, WI 54872<br />
County: Burnett<br />
nwjsiren@nwcgc.com<br />
Phone: (715) 349-2829<br />
Fax: (715) 349-2737<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/12/2001<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Children 1 w/Telehealth DHS 40.11(2)(a)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2405<br />
NORTHWEST JOURNEY - STEVENS POINT<br />
LAURA KOWALSKI<br />
525 - 4TH AVENUE<br />
STEVENS POINT, WI 54481<br />
County: Portage<br />
nwjstevenspo<strong>in</strong>t@nwcgc.com<br />
Phone: (715) 342-8065<br />
Fax: (715) 342-8073<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/14/2002<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Children 1 w/Telehealth DHS 40.11(2)(a)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/16/2011 01/31/2013<br />
02/01/2011 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 225 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2074<br />
NORTHWEST JOURNEY - SUPERIOR<br />
ANN PADUN<br />
1419 HILL AVENUE SUITE B<br />
SUPERIOR, WI 54880<br />
County: Douglas<br />
annp@nwcg.com<br />
Phone: (715) 395-3805<br />
Fax: (715) 395-3807<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1998<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Children 1 w/Telehealth DHS 40.11(2)(a)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2922<br />
NORTHWEST JOURNEY - WAUPACA<br />
HEATHER SAWYERS<br />
310 E MAIN STREET<br />
WEYAUWEGA, WI 54983<br />
County: Waupaca<br />
nwjwaupaca@nwcgc.com<br />
Phone: (920) 867-4744<br />
Fax: (920) 867-4213<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/05/2010<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
2404<br />
NORTHWEST JOURNEY - WAUSAU<br />
AMY MARTHALER<br />
2805 EMERY DRIVE<br />
WAUSAU, WI 54401<br />
County: Marathon<br />
amym@nwcgc.com<br />
Phone: (715) 675-5454<br />
Fax: (715) 675-0545<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/18/2002<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Children 1 w/Telehealth DHS 40.11(2)(a)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
NO BRANCH LOCATIONS<br />
09/01/2011 08/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/16/2011 01/31/2013<br />
02/01/2011 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 226 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2291<br />
NORTHWEST JOURNEY - WISCONSIN RAPIDS<br />
LAURA DUCKETT<br />
110 - 24TH STREET SOUTH<br />
WISCONSIN RAPIDS, WI 54494<br />
County: Wood<br />
No Email Address Provided<br />
Phone: (715) 424-5040<br />
Fax: (715) 424-5720<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/12/2001<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Children 1 w/Telehealth DHS 40.11(2)(a)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
1706<br />
NORTHWEST REGIONAL CENTER BEHAVIORAL<br />
HEALTH CLINIC (DIV OF CUMBERLAND MEM)<br />
BRUCE JUNGERBERG<br />
1150 - 6TH AVENUE<br />
CUMBERLAND, WI 54829<br />
County: Barron<br />
bjungerberg@cmhecu.com<br />
Phone: (715) 822-6169<br />
Fax: (715) 822-6248<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1993<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1707<br />
NORTHWEST REGIONAL CENTER<br />
BRENDA RUGGLES-PETERSON<br />
1110 - 7TH AVENUE<br />
CUMBERLAND, WI 54829<br />
County: Barron<br />
bruggles-peterson@cmhecu.com<br />
Phone: (715) 822-6135<br />
Fax: (715) 822-6220<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
06/16/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1977<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 07/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 227 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1709<br />
NORWOOD HEALTH CENTER<br />
KEN WAHLSTRAND<br />
1600 N. CHESTNUT AVENUE<br />
MARSHFIELD, WI 54449<br />
County: Wood<br />
No Email Address Provided<br />
Phone: (715) 384-2188<br />
Fax: (715) 389-2266<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/1980<br />
02/01/2011<br />
01/31/2013<br />
CSAS-Medically Monitored Residential Detox DHS 75.07<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
1710<br />
NOVA COUNSELING SERVICES, INC<br />
HUGH HOLLY<br />
3240 JACKSON STREET<br />
OSHKOSH, WI 54901<br />
County: W<strong>in</strong>nebago<br />
hugh@novaoshkosh.com<br />
Phone: (920) 231-0143<br />
Fax: (920) 231-4246<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1985<br />
05/01/2012<br />
04/30/2014<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Transitional Residential DHS 75.14<br />
2028<br />
OAKWOOD CLINICAL ASSOCIATES, LTD.<br />
AMY ANDERSON<br />
4109 - 67TH STREET<br />
KENOSHA, WI 53142<br />
County: Kenosha<br />
<strong>in</strong>fo@oakwoodcl<strong>in</strong>ical.com<br />
Phone: (414) 652-9830<br />
Fax: (262) 652-2931<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/25/1991<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
OAKWOOD CLINICAL ASSOCIATES LTD Tier 2<br />
24730 - 75TH ST<br />
03/01/2012<br />
PADDOCK LAKE, WI 53168<br />
02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2012 02/28/2014<br />
03/01/2012 02/28/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 228 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2675<br />
OCEANHAWK COUNSELING ALTERNATIVES, LLC<br />
JEAN DAUTE<br />
135 W MAIN STREET, #207A<br />
STOUGHTON, WI 53589<br />
County: Dane<br />
counsel<strong>in</strong>g@oceanhawk.net<br />
Phone: (608) 873-7838<br />
Fax: (608) 541-8351<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/17/2006<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1713<br />
O'CONNELL, LONG AND ASSOCIATES<br />
COUNSELING SERVICES<br />
TRUMAN G LONG<br />
1421 B RACINE STREET<br />
DELAVAN, WI 53115<br />
County: Walworth<br />
No Email Address Provided<br />
Phone: (262) 728-7844<br />
Fax: (262) 642-5146<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1988<br />
06/01/2008<br />
10/31/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2729<br />
OCONOMOWOC COMMUNITY SERVICES LLC<br />
DEBBIE FRISK<br />
36100 GENESEE LAKE ROAD<br />
OCONOMOWOC, WI 53066<br />
County: Waukesha<br />
dfrisk@odtc-wi.com<br />
Phone: (262) 569-5515<br />
Fax: (262) 569-9962<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2007<br />
05/01/2007<br />
04/30/2008<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
06/01/2008 10/31/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2007 04/30/2008
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 229 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1719<br />
OCONTO COUNTY DEPARTMENT OF HEALTH AND<br />
HUMAN SERVICES<br />
BRUCE RETZLAFF<br />
501 PARK AVENUE<br />
OCONTO, WI 54153<br />
County: Oconto<br />
bruce.retzlaff@co.oconto.wi.us<br />
Phone: (920) 834-7000<br />
Fax: (920) 834-6889<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/1979<br />
09/01/2012<br />
08/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
1720<br />
OMNE CLINIC, INC.<br />
MARK JUERGENS<br />
2005 HIGHLAND AVENUE<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
contact@omnecl<strong>in</strong>ic.com<br />
Phone: (715) 832-5454<br />
Fax: (715) 832-2991<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NEW VIEW INDUSTRIES Tier 1<br />
164 W PARK STREET<br />
09/01/2012<br />
GILLETT, WI 54124<br />
08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1987<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2413<br />
OMNI ENRICHMENT, INC.<br />
BARBARA TRIPP<br />
3020 W. VLIET STREET<br />
MILWAUKEE, WI 53208<br />
County: Milwaukee<br />
omnienrichment8814@att.net<br />
Phone: (414) 312-8910<br />
Fax: (414) 455-3292<br />
Surveyor: Demetrius Anderson<br />
Services<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014<br />
OMNE CLINIC INC Tier 2<br />
233 E LASALLE STREET<br />
10/01/2010<br />
BARRON, WI 54812<br />
09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2003<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 230 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2026<br />
OPEN DOOR CENTER FOR CHANGE, LLC<br />
CATHY PROPPER<br />
6502 GRAND TETON PLAZA, #206<br />
MADISON, WI 53719<br />
County: Dane<br />
Opendoorcfc@gmail.com<br />
Phone: (608) 827-7220<br />
Fax: (608) 827-7223<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1996<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2742<br />
OPTIONS COUNSELING SERVICES, LLC<br />
JIM WEBB<br />
1991 WINNEBAGO STREET<br />
RHINELANDER, WI 54501<br />
County: Oneida<br />
jwebb@optionscs.net<br />
Phone: (715) 362-5745<br />
Fax: (715) 362-2819<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/17/2007<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2419<br />
OPTIONS TREATMENT PROGRAMS, INC.<br />
KIMEKO HAGEN<br />
4000 W SPENCER STREET<br />
APPLETON, WI 54914<br />
County: Outagamie<br />
khagen@optionstx.com<br />
Phone: (920) 735-9010<br />
Fax: (920) 735-9050<br />
Surveyor: Frank Bellaire<br />
Services<br />
09/01/2010 08/31/2012<br />
OPTIONS COUNSELING SERVICES LLC Tier 2<br />
21A SOUTH BROWN STREET<br />
04/01/2012<br />
RHINELANDER, WI 54501<br />
03/31/2014<br />
OPTIONS COUNSELING SERVICES LLC Tier 1<br />
9433 COUNTY RD J, PO BOX 27<br />
04/01/2012<br />
MINOCQUA, WI 54548<br />
03/31/2014<br />
OPTIONS COUNSELING SERVICES LLC Tier 1<br />
722 EAST WALL STREET<br />
04/01/2012<br />
EAGLE RIVER, WI 54521<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/20/2002<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
APPLETON WEST HIGH SCHOOL Tier 1<br />
610 N BADGER AVENUE<br />
04/01/2012<br />
APPLETON, WI 54914<br />
03/31/2014<br />
OPTIONS TREATMENT PROGRAM Tier 2<br />
424 S MONROE AVENUE, #201<br />
04/01/2012<br />
GREEN BAY, WI 54301<br />
03/31/2014<br />
OPTIONS TREATMENT PROGRAMS, INC Tier 2<br />
922 CHURCHILL ST<br />
04/01/2012<br />
WAUPACA, WI 54981<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 231 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2513<br />
OREGON MENTAL HEALTH SERVICES<br />
MARY SELLA<br />
602 PLEASANT OAK DRIVE SUITE D<br />
OREGON, WI 53575<br />
County: Dane<br />
marysella.omhs@gmail.com<br />
Phone: (608) 835-5050<br />
Fax: (608) 835-5010<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/2004<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2309<br />
ORION FAMILY SERVICES, INC.<br />
STACEY PARKE<br />
6333 ODANA ROAD, #20<br />
MADISON, WI 53719<br />
County: Dane<br />
sparke@orionfamilyservices.org<br />
Phone: (608) 270-2511<br />
Fax: (608) 270-0467<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
OREGON MENTAL HEALTH SERVICES<br />
LLC<br />
110 W. LINDEN DRIVE SUITE B<br />
JEFFERSON, WI 53549<br />
Tier 1<br />
05/01/2011<br />
04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/12/2001<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1723<br />
OSHKOSH COUNSELING CENTER, INC.<br />
RACHELLE LAUX<br />
501 MERRITT AVENUE<br />
OSHKOSH, WI 54901<br />
County: W<strong>in</strong>nebago<br />
occ@oshcc.com<br />
Phone: (920) 231-2858<br />
Fax: (920) 231-4048<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1985<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 232 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2566<br />
OSWALD COUNSELING ASSOCIATES<br />
LYNNE OSWALD<br />
2450 VINEYARD DRIVE<br />
PLOVER, WI 54467<br />
County: Portage<br />
oca<strong>in</strong>c@sbcglobal.net<br />
Phone: (715) 342-0290<br />
Fax: (715) 342-0291<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/14/2005<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1724<br />
OUTAGAMIE COUNTY DEPARTMENT OF HEALTH<br />
& HUMAN SERVICES<br />
BRIAN BEZIER, PSYD<br />
401 S. ELM STREET<br />
APPLETON, WI 54911<br />
County: Outagamie<br />
humansvc@co.outagamie.wi.us<br />
Phone: (920) 832-5270<br />
Fax: (920) 832-5488<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1987<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2314<br />
OUTAGAMIE COUNTY DEPARTMENT OF HEALTH<br />
AND HUMAN SERVICES CSP<br />
ROSEMARY DAVIS<br />
401 S. ELM STREET<br />
APPLETON, WI 54911<br />
County: Outagamie<br />
rosemary.davis@outagamie.org<br />
Phone: (920) 832-5270<br />
Fax: (920) 832-5488<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1987<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 233 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2590<br />
OUTAGAMIE COUNTY HEALTH AND HUMAN<br />
SERVICES COMPREHENSIVE COMMUNITY<br />
SERVCIES<br />
JUDY VAN RYZIN<br />
401 S. ELM STREET<br />
APPLETON, WI 54911<br />
County: Outagamie<br />
vanryzjm@co.outagamie.wi.us<br />
Phone: (920) 832-5270<br />
Fax: (920) 832-5488<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/2005<br />
04/01/2011<br />
03/31/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
2246<br />
OUTREACH COMMUNITY HEALTH CENTERS, INC.<br />
MICHAEL BAUER<br />
210 W. CAPITOL DRIVE<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
MichaelB@orchc-milw.org<br />
Phone: (414) 727-6320<br />
Fax: (414) 727-6321<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2000<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2743<br />
PALMER COUNSELING, LLC<br />
JEFF PALMER<br />
1039 W MASON STREET<br />
GREEN BAY, WI 54311<br />
County: Brown<br />
palmercounsel<strong>in</strong>g@hotmail.com<br />
Phone: (920) 965-7725<br />
Fax: (920) 496-7922<br />
Surveyor: Frank Bellaire<br />
Services<br />
OUTREACH COMMUNITY HEALTH<br />
CENTER<br />
711 W CAPITOL DRIVE<br />
MILWAUKEE, WI 53206<br />
04/01/2011 03/31/2013<br />
Tier 1<br />
08/01/2012<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/06/2007<br />
08/01/2008<br />
07/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2008 07/31/2010
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 234 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2723<br />
PARK WEST SOCIAL & PSYCHOTHERAPY<br />
SERVICES INC<br />
CLORINE HARRIS<br />
2772 N MARTIN LUTHER KING DRIVE #102<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
charris892@wi.rr.com<br />
Phone: (414) 771-0227<br />
Fax: (414) 771-0227<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/06/2007<br />
05/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1727<br />
PARKLAND CLINIC<br />
MUNI H PATEL<br />
2600 N. MAYFAIR ROAD, #850<br />
MILWAUKEE, WI 53226<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 771-2088<br />
Fax: (414) 771-6308<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/15/1991<br />
06/01/2009<br />
05/31/2011<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2489<br />
PARKVIEW COUNSELING ASSOCIATES, LLC<br />
NANCY A. SHIRK<br />
107 DIVISION STREET<br />
PLYMOUTH, WI 53073<br />
County: Sheboygan<br />
nshirk@wi.rr.com<br />
Phone: (920) 892-7788<br />
Fax: (920) 893-5459<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/17/2003<br />
11/01/2007<br />
10/31/2009<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
06/01/2009 05/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2007 10/31/2009
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 235 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1728<br />
PASTORAL COUNSELING SERVICE OF THE<br />
GREATER MILWAUKEE AREA<br />
STEVEN FRINGER<br />
2825 N. MAYFAIR ROAD STE 101<br />
WAUWATOSA, WI 53222<br />
County: Milwaukee<br />
pcs-counsel<strong>in</strong>g@wi.twcbc.com<br />
Phone: (414) 453-6960<br />
Fax: (414) 453-7080<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/07/1995<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1910<br />
PATHFINDERS MILWAUKEE, INC<br />
CATHY ARNEY<br />
4200 N HOLTON STREET, #400<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
carney@pathf<strong>in</strong>dersmke.org<br />
Phone: (414) 964-2565<br />
Fax: (414) 964-0102<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
PASTORAL COUNSELING SERV OF<br />
GREATER MILW<br />
745 MAIN STREET<br />
RACINE, WI 53403<br />
PASTORAL COUNSELING SERV OF<br />
GREATER MILW AREA<br />
4465 N OAKLAND AVENUE<br />
SHOREWOOD, WI 53211<br />
Tier 1<br />
08/01/2012<br />
07/31/2014<br />
Tier 1<br />
08/01/2012<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2011<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1729<br />
PATHWAY CLINIC, S.C.<br />
SANDRA JENSEN<br />
560 - 4TH STREET<br />
PRAIRIE DU SAC, WI 53578<br />
County: Sauk<br />
sjensen@pathwaycl<strong>in</strong>ic.com<br />
Phone: (608) 643-3663<br />
Fax: (608) 643-5014<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1984<br />
01/01/2012<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
06/01/2012 05/31/2014<br />
PATHWAY CLINIC SC Tier 1<br />
436 SUNRISE DR<br />
01/01/2012<br />
SPRING GREEN, WI 53588<br />
12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2012<br />
01/01/2012 12/31/2012<br />
01/01/2012 12/31/2012<br />
01/01/2012 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 236 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2248<br />
PATHWAYS CONSULTING<br />
SHARON O'BRIEN<br />
6121 GREEN BAY ROAD, #220<br />
KENOSHA, WI 53142<br />
County: Kenosha<br />
No Email Address Provided<br />
Phone: (262) 652-7222<br />
Fax: (262) 652-1734<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/06/2000<br />
09/01/2009<br />
08/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1730<br />
PATHWAYS COUNSELING CENTER<br />
SALLY TARVID<br />
13105 W. BLUEMOUND ROAD, #100<br />
BROOKFIELD, WI 53005<br />
County: Waukesha<br />
pathwaycc@sbcglobal.net<br />
Phone: (262) 641-9790<br />
Fax: (262) 641-9791<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1985<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2792<br />
PEACE TREE COUNSELING, LLC<br />
VALERIE ZELLMER<br />
204 THIRD AVENUE<br />
OSCEOLA, WI 54020<br />
County: Polk<br />
peacetree@centurytel.net<br />
Phone: (715) 755-2233<br />
Fax: (715) 755-3966<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2009 08/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/24/2008<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
02/01/2012 01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2011 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 237 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2715<br />
PEACEFUL SOLUTIONS COUNSELING<br />
LEE SHIPWAY<br />
1720 MERRILL AVENUE, #300<br />
WAUSAU, WI 54401<br />
County: Marathon<br />
lee@peacefulsolutions.org<br />
Phone: (715) 675-3458<br />
Fax: (715) 675-7238<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/2007<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2923<br />
PENFIELD CHILDREN'S CENTER<br />
HEATHER ROTOLO<br />
833 N 26TH STREET<br />
MILWAUKEE, WI 53233<br />
County: Milwaukee<br />
heatherrotolo@penfieldchildren.org<br />
Phone: (414) 345-6337<br />
Fax: (414) 344-7739<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2010<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1733<br />
PERFORMANCE ENHANCEMENT HEALTH<br />
SERVICES, SC<br />
JODI PETERNEL<br />
8800 W 102ND STREET #103<br />
FRANKLIN, WI 53132<br />
County: Milwaukee<br />
pepetjodi@hotmail.com<br />
Phone: (414) 858-1014<br />
Fax: (414) 858-1017<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/11/1991<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
PERFORMANCE ENHANCEMENT<br />
HEALTH SERVICES SC<br />
7418 TICHIGAN ROAD<br />
WATERFORD, WI 53185<br />
10/01/2011 09/30/2013<br />
Tier 1<br />
02/01/2012<br />
01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 238 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2602<br />
PHOENIX ALTERNATIVES, LLC<br />
LOUISE GRUENWALD<br />
3934 TOWER DRIVE<br />
EAU CLAIRE, WI 54703<br />
County: Eau Claire<br />
stacys@phoenixalternative.net<br />
Phone: (715) 830-8270<br />
Fax: (715) 830-8272<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/02/2005<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
1591<br />
PHOENIX BEHAVIORAL HEALTH SERVICES, LLC<br />
JOHN LALIBERTE<br />
115 E. WALDO BOULEVARD<br />
MANITOWOC, WI 54220<br />
County: Manitowoc<br />
<strong>in</strong>fo@phoenixbhc.com<br />
Phone: (920) 682-1131<br />
Fax: (920) 682-5087<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/26/1991<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2963<br />
PIERCE COUNTY DEPARTMENT OF HUMAN<br />
SERVICES/NORTHWEST CONNECTION<br />
RON KIESLER<br />
412 W. KINNE STREET<br />
ELLSWORTH, WI 54011<br />
County: Pierce<br />
ron.kiesler@co.pierce.wi.us<br />
Phone: (715) 273-6770<br />
Fax: (715) 273-6862<br />
Surveyor: Polly Wong<br />
Services<br />
PHOENIX BEHAVIORAL HEALTH<br />
SERVICES, LLC<br />
807 CENTER STREET<br />
SHEBOYGAN, WI 53081<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013<br />
Tier 1<br />
11/01/2010<br />
10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011<br />
11/01/2012<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2012 03/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 239 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1737<br />
PIERCE COUNTY DEPARTMENT OF HUMAN<br />
SERVICES<br />
RON KIESLER<br />
412 W. KINNE STREET<br />
ELLSWORTH, WI 54011<br />
County: Pierce<br />
ron.kiesler@co.pierce.wi.us<br />
Phone: (715) 273-6770<br />
Fax: (715) 273-6862<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/1981<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 2 DHS 34.2<br />
1738<br />
PLATTEVILLE FAMILY RESOURCE CENTER, INC.<br />
MARC K. WRUBLE<br />
1155 N ELM STREET, #120<br />
PLATTEVILLE, WI 53818<br />
County: Grant<br />
drwruble@gmail.com<br />
Phone: (608) 348-4060<br />
Fax: (608) 348-4191<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/08/1995<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2465<br />
PLESHE COUNSELING SERVICES<br />
KAREN PLESHE<br />
2631 S PACKERLAND DRIVE, #104E<br />
GREEN BAY, WI 54313<br />
County: Brown<br />
kpleshe79@yahoo.com<br />
Phone: (920) 884-1145<br />
Fax: (920) 632-4478<br />
Surveyor: Frank Bellaire<br />
Services<br />
PLATTEVILLE FAMILY RESOURCE<br />
CENTER INC<br />
731 CLAY STREET<br />
DARLINGTON, WI 53530<br />
PLATTEVILLE FAMILY RESOURCE<br />
CENTER, INC<br />
8820 HWY 35 & 61<br />
LANCASTER, WI 53813<br />
PLATTEVILLE FAMILY RESOURCE<br />
CENTER, INC<br />
700 MAIN STREET<br />
DARLINGTON, WI 53530<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
04/01/2011 10/31/2011<br />
Tier 1<br />
10/01/2010<br />
11/30/2010<br />
Tier 1<br />
11/09/2011<br />
09/30/2012<br />
Tier 1<br />
12/01/2010<br />
09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/25/2003<br />
09/01/2009<br />
08/31/2010<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
10/01/2010 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2009 08/31/2010
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 240 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2222<br />
POLK COUNTY HUMAN SERVICES DEPARTMENT<br />
CSP<br />
LINDA MILLS-KREBSBACH<br />
100 POLK COUNTY PLAZA, #50<br />
BALSAM LAKE, WI 54810<br />
County: Polk<br />
l<strong>in</strong>damk@co.polk.wi.us<br />
Phone: (715) 485-8400<br />
Fax: (715) 485-8490<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/26/2000<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2204<br />
POLK COUNTY MENTAL AND BEHAVIORAL<br />
HEALTH SERVICES<br />
KAY CONFER<br />
100 POLK COUNTY PLAZA, #50<br />
BALSAM LAKE, WI 54810<br />
County: Polk<br />
kayC@co.polk.wi.us<br />
Phone: (715) 485-8400<br />
Fax: (715) 485-8490<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/08/2000<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2712<br />
PORTAGE COUNTY HEALTH & HUMAN SERVICES<br />
COMPREHENSIVE COMMUNITY SERVICES<br />
AMY MARCOTT<br />
817 WHITING AVENUE<br />
STEVENS POINT, WI 54481<br />
County: Portage<br />
marcotta@co.portage.wi.us<br />
Phone: (715) 345-5350<br />
Fax: (715) 345-5966<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2007<br />
03/01/2011<br />
02/28/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2011 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 241 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1740<br />
PORTAGE COUNTY HEALTH & HUMAN SERVICES<br />
AMY MARCOTT<br />
817 WHITING AVENUE<br />
STEVENS POINT, WI 54481<br />
County: Portage<br />
marcotta@co.portage.wi.us<br />
Phone: (715) 345-5810<br />
Fax: (715) 345-5966<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/1976<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2773<br />
PORTIS MARRIAGE AND CHILDREN COUNSELING<br />
CLINIC LLC<br />
ALICE PORTIS-PATTERSON<br />
5801 WASHINGTON AVENUE, #110<br />
RACINE, WI 53406<br />
County: Rac<strong>in</strong>e<br />
pmccounsel<strong>in</strong>g@wi.twcbc.com<br />
Phone: (262) 884-9734<br />
Fax: (262) 884-9735<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/05/2008<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2796<br />
POSITIVE OUTLOOK CLINICAL SERVICES LLC<br />
PAMELA HANSEN<br />
3353 N DR MARTIN LUTHER KING DRIVE<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
Positiveoutlook2006@yahoo.com<br />
Phone: (414) 460-6995<br />
Fax: (414) 355-5467<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2008<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2011 07/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 242 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2929<br />
POWER FOR CHANGE, LLC<br />
STEVE SHEFCHIK<br />
1039 W MASON STREET<br />
GREEN BAY, WI 54303<br />
County: Brown<br />
sasmagic@sbcglobal.net<br />
Phone: (290) 965-7707<br />
Fax: (920) 496-7922<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/13/2010<br />
11/01/2011<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1741<br />
POYNETTE COUNSELING & PSYCHOTHERAPY<br />
ASSOCIATES, INC.<br />
LORI A GOESER<br />
415 N. MAIN STREET, #3<br />
POYNETTE, WI 53955<br />
County: Columbia<br />
lori.goeser@poynettecounsel<strong>in</strong>g.com<br />
Phone: (608) 635-2146<br />
Fax: (608) 635-7379<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1989<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1742<br />
PRAIRIE COUNSELING SERVICES<br />
KATHRYN HUBBARD<br />
1460 W. MAIN STREET #6<br />
SUN PRAIRIE, WI 53590<br />
County: Dane<br />
prairiec@netzero.net<br />
Phone: (608) 837-4814<br />
Fax: (608) 825-4933<br />
Surveyor: William Rohner<br />
Services<br />
11/01/2011 10/31/2012<br />
MAUSTON COUNSELING Tier 1<br />
1040 DIVISION STREET<br />
12/01/2011<br />
MAUSTON, WI 53948<br />
11/30/2013<br />
POYNETTE COUNSELING &<br />
PSYCHOTHERAPY ASSO<br />
Tier 1<br />
4915 MONONA DR<br />
12/01/2011<br />
MADISON, WI 53716<br />
11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1978<br />
08/01/2012<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 07/31/2013<br />
08/01/2012 07/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 243 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1743<br />
PREVEA CLINIC BEHAVIORAL CARE<br />
JEFFREY STUMBRAS<br />
2680 VERNON DRIVE<br />
GREEN BAY, WI 54304<br />
County: Brown<br />
Jeffs@prevea.com<br />
Phone: (920) 272-1200<br />
Fax: (920) 272-1201<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/09/1996<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2644<br />
PRICE COUNTY HUMAN SERVICES/COUNSELING<br />
AND DEVELOPMENT CENTER<br />
MARY HAHN<br />
104 S EYDER<br />
PHILLIPS, WI 54555<br />
County: Price<br />
mary.hahn@co.price.wi.us<br />
Phone: (715) 339-2158<br />
Fax: (715) 339-4018<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
PREVEA CLINIC BEHAVIORAL CARE Tier 1<br />
3021 VOYAGER DRIVE<br />
01/01/2012<br />
GREEN BAY, WI 54311<br />
12/31/2013<br />
PREVEA CLINIC BEHAVIORAL CARE Tier 1<br />
1715 DOUSMAN ST<br />
01/01/2012<br />
GREEN BAY, WI 54303<br />
12/31/2013<br />
PREVEA CLINIC BEHAVIORAL CARE Tier 1<br />
1821 WEBSTER AVE<br />
01/01/2012<br />
GREEN BAY, WI 54301<br />
12/31/2013<br />
PREVEA CLINIC BEHAVIORAL CARE Tier 1<br />
2793 LINEVILLE ROAD<br />
01/01/2012<br />
GREEN BAY, WI 54313<br />
12/31/2013<br />
PREVEA CLINIC BEHAVIORAL CARE Tier 1<br />
1727 SHAWANO AVENUE<br />
01/01/2012<br />
GREEN BAY, WI 54303<br />
12/31/2013<br />
PREVEA HEALTH LUXEMBURG Tier 1<br />
101 SCHOOL CREEK TRAIL<br />
08/15/2012<br />
LUXEMBURG, WI 54217<br />
12/31/2013<br />
PREVEA PULASKI HEALTH CENTER Tier 1<br />
940 S AUGUSTINE STREET<br />
01/01/2012<br />
PULASKI, WI 54162<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2006<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2011 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 244 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2531<br />
PRICE-DECKER CLINIC, LLC<br />
TERRY PRICE-DECKER<br />
48 W KING STREET<br />
RHINELANDER, WI 54501<br />
County: Oneida<br />
terrypd@frontier.com<br />
Phone: (715) 362-5437<br />
Fax: (715) 362-2014<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/2004<br />
09/01/2012<br />
08/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2879<br />
PRIMARY CONNECTION HEALTH CARE, INC. DBA<br />
BRIDGE COMMUNITY HEALTH CLINIC<br />
ELLEN BARKER<br />
1810 N SECOND STREET<br />
WAUSAU, WI 54403<br />
County: Marathon<br />
ellenb@bridgecl<strong>in</strong>ic.org<br />
Phone: (715) 848-4884<br />
Fax: (715) 845-5385<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
PRICE-DECKER CLINIC LLC Tier 1<br />
6930 W SCHOOL STREET<br />
09/01/2012<br />
THREE LAKES, WI 54562<br />
08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2009<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1746<br />
PROFESSIONAL PSYCHOLOGICAL SERVICES,<br />
S.C.<br />
DEAN STOLLDORF, PHD<br />
441 MILWAUKEE STREET, #2<br />
BURLINGTON, WI 53105<br />
County: Rac<strong>in</strong>e<br />
pps@execpc.com<br />
Phone: (262) 767-0440<br />
Fax: (262) 767-0777<br />
Surveyor: William Rohner<br />
Services<br />
BRIDGE CLINIC @ ASPIRUS BEHAV MED<br />
CLINIC<br />
520 N 28TH AVENUE, #200<br />
RIB MOUNTAIN, WI 54401<br />
09/01/2012 08/31/2014<br />
Tier 1<br />
08/01/2012<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1991<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2011 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 245 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1747<br />
PROFESSIONAL RECOVERY NETWORK -<br />
HERRINGTON RECOVERY CENTER<br />
ELIZABETH GILBERT<br />
34700 VALLEY ROAD<br />
OCONOMOWOC, WI 53066<br />
County: Waukesha<br />
No Email Address Provided<br />
Phone: (262) 549-6600<br />
Fax: (262) 549-6698<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/15/1997<br />
06/01/2008<br />
05/31/2010<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1749<br />
PROFESSIONAL SERVICES GROUP, INC.<br />
BRIAN WOLF<br />
2108 - 63RD STREET<br />
KENOSHA, WI 53143<br />
County: Kenosha<br />
bwolf@psycip.com<br />
Phone: (262) 652-2406<br />
Fax: (262) 652-2408<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1983<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1750<br />
PROGRAM FOR ASSERTIVE COMMUNITY<br />
TREATMENT (PACT)<br />
JANA LANE FREY<br />
600 WILLIAMSON STREET, #A-B<br />
MADISON, WI 53703<br />
County: Dane<br />
Jana.Frey@dhs.wiscons<strong>in</strong>.gov<br />
Phone: (608) 266-0721<br />
Fax: (608) 261-8055<br />
Surveyor: William Rohner<br />
Services<br />
06/01/2008 05/31/2010<br />
PROFESSIONAL SERVICES GROUP Tier 2<br />
1126 S 70TH STREET, #208<br />
04/01/2012<br />
WEST ALLIS, WI 53214<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1989<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 246 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1751<br />
PROJECT ACCESS, INC. CSP<br />
C ROGER ZHONG<br />
823 S 60TH STREET<br />
MILWAUKEE, WI 53214<br />
County: Milwaukee<br />
projectaccess<strong>in</strong>c@yahoo.com<br />
Phone: (414) 456-1155<br />
Fax: (414) 456-1655<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/20/1995<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2942<br />
PROMISES COUNSELING SERVICES LLC<br />
RISA L. JANOWSKI<br />
2701 LARSEN RD<br />
GREEN BAY, WI 54303<br />
County: Brown<br />
promisescounsel<strong>in</strong>g@gmail.com<br />
Phone: (920) 593-8040<br />
Fax: (920) 593-8041<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/25/2011<br />
06/06/2011<br />
05/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1445<br />
PSYCARE-MILWAUKEE LLC<br />
THOMAS A GARLAND<br />
633 W. WISCONSIN AVENUE, #1810<br />
MILWAUKEE, WI 53203<br />
County: Milwaukee<br />
psycaremilwaukee@aol.com<br />
Phone: (414) 271-3322<br />
Fax: (414) 271-2335<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1982<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
06/06/2011 05/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 247 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1752<br />
PSYCHIATRIC AND PSYCHOTHERAPY CLINIC<br />
PAUL DEFAZIO<br />
3601 - 30TH AVENUE, #102<br />
KENOSHA, WI 53144<br />
County: Kenosha<br />
No Email Address Provided<br />
Phone: (262) 654-0487<br />
Fax: (262) 654-2434<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/1980<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1754<br />
PSYCHIATRIC ASSOCIATES COUNSELING<br />
CENTER, LLC<br />
JULIE NOTH<br />
122 W SOUTH STREET<br />
VIROQUA, WI 54665<br />
County: Vernon<br />
JCN1@mwt.net<br />
Phone: (608) 637-2511<br />
Fax: (608) 637-7921<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/1987<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1757<br />
PSYCHIATRIC SERVICES OF RACINE LLP<br />
PENNY ROGINSKI<br />
1244 WISCONSIN AVENUE, #303<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
bompsychservices@tds.net<br />
Phone: (262) 635-5520<br />
Fax: (262) 635-5530<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1988<br />
11/01/2011<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
06/01/2012 05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 248 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1761<br />
PSYCHOLOGICAL AND COUNSELING SERVICES<br />
DR JEFFREY ADAMCZAK<br />
6929 MARINER DRIVE, #D<br />
RACINE, WI 53406<br />
County: Rac<strong>in</strong>e<br />
drjeffpsy@yahoo.com<br />
Phone: (262) 886-3322<br />
Fax: (262) 571-9648<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/15/1992<br />
09/01/2009<br />
08/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2806<br />
PSYCHOLOGICAL RESOURCE CENTER, LLC<br />
ELIZABETH K MCCLUSKEY<br />
1218 N 4TH STREET, #108<br />
TOMAHAWK, WI 54487<br />
County: L<strong>in</strong>coln<br />
laura@pscyhresctr.com<br />
Phone: (715) 224-2100<br />
Fax: (715) 224-2106<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
PSYCHOLOGICAL AND COUNSELING<br />
SERVICES<br />
8825 S HOWELL AVENUE, #301<br />
OAK CREEK, WI 53154<br />
PSYCHOLOGICAL AND COUNSELING<br />
SERVICES<br />
8405 - 104TH AVENUE<br />
PLEASANT PRAIRIE, WI 53158<br />
PSYCHOLOGICAL AND COUNSELING<br />
SERVICES<br />
7300 S 13TH STREET, #201<br />
OAK CREEK, WI 53154<br />
PSYCHOLOGICAL AND COUNSELING<br />
SERVICES<br />
919 - 60TH STREET<br />
KENOSHA, WI 53140<br />
Tier 1<br />
09/01/2009<br />
01/02/2010<br />
Tier 1<br />
01/03/2010<br />
08/31/2011<br />
Tier 1<br />
01/03/2010<br />
08/31/2011<br />
Tier 1<br />
09/01/2009<br />
01/02/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2008<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1766<br />
PSYCHOLOGY ASSOCIATES OF MADISON, LLP<br />
LYNN CATLIN, PHD<br />
122 E. OLIN AVENUE, #220<br />
MADISON, WI 53713<br />
County: Dane<br />
lynn.catl<strong>in</strong>@gmail.com<br />
Phone: (608) 255-9119<br />
Fax: (608) 255-9219<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2009 08/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1991<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
10/01/2010 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 249 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1410<br />
PSYCHOTHERAPY AND GROWTH CENTER<br />
TAMARA SCHLESSINGER<br />
660 W WASHINGTON, #307<br />
MADISON, WI 53703<br />
County: Dane<br />
No Email Address Provided<br />
Phone: (608) 255-0669<br />
Fax: (608) 255-0667<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1990<br />
11/01/2009<br />
10/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2236<br />
QAM - QUALITY ADDICTION MANAGEMENT<br />
CHARLES ENGEL<br />
1610 MILLER PARKWAY<br />
WEST MILWAUKEE, WI 53214<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 672-3804<br />
Fax: (414) 672-6026<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/19/2000<br />
09/01/2010<br />
08/31/2012<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1748<br />
QAM-QUALITY ADDICTION MANAGEMENT<br />
ELIZABETH GILBERT<br />
2422 N. GRANDVIEW BOULEVARD<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
egilbert@qam-<strong>in</strong>c.com<br />
Phone: (262) 549-6600<br />
Fax: (262) 549-6698<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2009 10/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1994<br />
09/01/2010<br />
08/31/2012<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
09/01/2010 08/31/2012<br />
09/01/2010 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2010 08/31/2012<br />
09/01/2010 08/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 250 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2341<br />
QAM-QUALITY ADDICTION MANAGMENT<br />
CHARLES J ENGEL, MD<br />
5735 DURAND AVENUE<br />
RACINE, WI 53406<br />
County: Rac<strong>in</strong>e<br />
No Email Address Provided<br />
Phone: (262) 598-1392<br />
Fax: (262) 598-1395<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/12/2001<br />
12/10/2010<br />
08/31/2012<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1768<br />
QUAD/MED, LLC, SUBSTANCE ABUSE<br />
COUNSELING SERVICES<br />
MEGHAN BAHR<br />
W227 N6103 SUSSEX ROAD<br />
SUSSEX, WI 53089<br />
County: Waukesha<br />
meghan.bahr@quadmedical.com<br />
Phone: (414) 566-8030<br />
Fax: (414) 566-8038<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1995<br />
12/01/2011<br />
11/30/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2487<br />
QUALITY ADDICTION MANAGEMENT - QAM<br />
ELIZABETH GILBERT<br />
2979 ALLIED STREET, #C<br />
GREEN BAY, WI 54304<br />
County: Brown<br />
egilbert@qam-<strong>in</strong>c.com<br />
Phone: (920) 337-6740<br />
Fax: (920) 337-6741<br />
Surveyor: Frank Bellaire<br />
Services<br />
12/10/2010 08/31/2012<br />
12/10/2010 08/31/2012<br />
QUAD/GAPHICS Tier 1<br />
N63 W23075 HWY 75<br />
12/01/2011<br />
SUSSEX, WI 53089<br />
11/30/2013<br />
QUAD/GRAPHICS Tier 1<br />
555 S 108TH STREET<br />
12/01/2011<br />
MILWAUKEE, WI 53214<br />
11/30/2013<br />
QUAD/GRAPHICS Tier 1<br />
952 BADGER ROAD<br />
12/01/2011<br />
LOMIRA, WI 53048<br />
11/30/2013<br />
QUAD/GRAPHICS Tier 1<br />
1900 W SUMMER STREET<br />
12/01/2011<br />
HARTFORD, WI 53027<br />
11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/20/2003<br />
11/01/2010<br />
10/31/2012<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 251 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2595<br />
QUALITY ADDICTION MANAGEMENT, INC.<br />
ELIZABETH GILBERT<br />
151 E BADGER ROAD, #A<br />
MADISON, WI 53713<br />
County: Dane<br />
egilbert@qam-<strong>in</strong>c.com<br />
Phone: (608) 250-2512<br />
Fax: (608) 250-2516<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/11/2005<br />
07/01/2011<br />
06/30/2013<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2686<br />
QUALITY ADDICTION MANAGEMENT, INC.<br />
WENDY KOHLHAAS<br />
2240 PRAIRIE AVENUE, #10<br />
BELOIT, WI 53511<br />
County: Rock<br />
No Email Address Provided<br />
Phone: (608) 361-7200<br />
Fax: (608) 361-7201<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/06/2006<br />
10/01/2011<br />
09/30/2013<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2931<br />
QUALITY ADDICTION MANAGEMENT<br />
ELIZABETH GILBERT<br />
2842 S BUSINESS DRIVE<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
egilbert@qam-<strong>in</strong>c.com<br />
Phone: (920) 458-6527<br />
Fax: (920) 458-6623<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/03/2011<br />
01/01/2012<br />
12/31/2012<br />
CSAS-Narcotic Treatment DHS 75.15<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2012<br />
01/01/2012 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 252 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2828<br />
RACINE COMMUNITY HEALTH CENTER<br />
AMY BARBER<br />
2405 NORTHWESTERN AVENUE<br />
RACINE, WI 53404<br />
County: Rac<strong>in</strong>e<br />
No Email Address Provided<br />
Phone: (262) 886-0474<br />
Fax: (262) 886-1672<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/2008<br />
07/01/2010<br />
08/04/2010<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2952<br />
RACINE COUNTY HUMAN SERVICES<br />
DEPARTMENT COMMUNITY SUPPORT PROGRAM<br />
MICHELLE GOGGINS<br />
1717 TAYLOR AVENUE<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
michelle.gogg<strong>in</strong>s@gorac<strong>in</strong>e.org<br />
Phone: (262) 638-6633<br />
Fax: (262) 638-6983<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2011<br />
12/01/2011<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2490<br />
RACINE COUNTY HUMAN SERVICES<br />
DEPARTMENT<br />
MICHELLE GOGGINS<br />
1717 TAYLOR AVENUE<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
michelle.gogg<strong>in</strong>s@gorac<strong>in</strong>e.org<br />
Phone: (262) 638-6633<br />
Fax: (262) 638-6978<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2010 08/04/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/14/2004<br />
01/01/2012<br />
12/31/2012<br />
CSAS-Emergency Outpatient DHS 75.05<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/02/2012 12/31/2012<br />
01/01/2012 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 253 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2220<br />
RACINE PSYCHOLOGICAL SERVICES, INC.<br />
MARY JANE WHITMORE<br />
840 LAKE AVENUE, #101<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
Rac<strong>in</strong>ePsychSvc@aol.com<br />
Phone: (262) 634-8688<br />
Fax: (262) 634-7547<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/31/2000<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2118<br />
RAVENSWOOD CLINIC<br />
ANTHONY F. WERTH, JR.<br />
2266 N. PROSPECT AVENUE, #326<br />
MILWAUKEE, WI 53202<br />
County: Milwaukee<br />
awerth@ravenswoodcl<strong>in</strong>ic.org<br />
Phone: (414) 224-0492<br />
Fax: (414) 224-8112<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
RACINE PSYCHOLOGICAL SERVICES INC Tier 1<br />
209 N MAIN STREET<br />
04/01/2011<br />
BURLINGTON, WI 53105<br />
03/31/2013<br />
RACINE PSYCHOLOGICAL SERVICES,<br />
INC.<br />
Tier 2<br />
1717 TAYLOR AVE<br />
11/25/2011<br />
RACINE, WI 53403<br />
03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/23/1999<br />
09/01/2011<br />
08/31/2013<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2750<br />
RAWHIDE YOUTH & FAMILY COUNSELING<br />
SERVICES<br />
KELLY WISNEFSKE<br />
E7475 RAWHIDE ROAD<br />
NEW LONDON, WI 54961<br />
County: Waupaca<br />
Kwisnefske@rawhide.org<br />
Phone: (877) 300-9101<br />
Fax: (920) 982-5040<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/23/2007<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
RAWHIDE YOUTH & FAMILY<br />
COUNSELING SVS<br />
446 WESTHILL BLVD SUITE 6<br />
APPLETON, WI 54914<br />
RAWHIDE YOUTH & FAMILY<br />
COUNSELING SVS<br />
926 WILLARD DRIVE SUITE 228<br />
GREEN BAY, WI 54303<br />
RAWHIDE YOUTH & FAMILY<br />
COUNSELING SVS<br />
6045 N GREEN BAY AVENUE<br />
GLENDALE, WI 53209<br />
RAWHIDE YOUTH & FAMILY<br />
COUNSELING SVS<br />
303 N MAIN STREET, #201<br />
WEST BEND, WI 53095<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
Tier 1<br />
09/14/2011<br />
08/31/2013<br />
Tier 1<br />
09/01/2011<br />
08/31/2013<br />
Tier 1<br />
09/01/2011<br />
08/31/2013<br />
Tier 1<br />
09/01/2011<br />
08/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2011 08/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 254 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1830<br />
REACH COUNSELING SERVICES<br />
LYN BEYER<br />
1370 S COMMERCIAL STREET<br />
NEENAH, WI 54956<br />
County: W<strong>in</strong>nebago<br />
lyns@reachcounsel<strong>in</strong>g.com<br />
Phone: (920) 722-8150<br />
Fax: (920) 722-0142<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/11/1993<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2882<br />
REACH, INC. COMPREHENSIVE MENTAL HEALTH<br />
CLINIC<br />
CANDICE LIPSKI<br />
6310 N PORT WASHINGTON ROAD<br />
GLENDALE, WI 53217<br />
County: Milwaukee<br />
reachmentalhealthcl<strong>in</strong>ic@hotmail.com<br />
Phone: (414) 961-1600<br />
Fax: (414) 961-1616<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
REACH COUNSELING SERVICES Tier 1<br />
2525 BOWEN STREET<br />
01/01/2011<br />
OSHKOSH, WI 54901<br />
12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2009<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1775<br />
RECONNECTIONS<br />
No Contact Name Provided<br />
921 W. GLENDALE AVENUE<br />
GLENDALE, WI 53209<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 221-9293<br />
Fax: No Number Provided<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/09/1996<br />
01/01/2009<br />
12/31/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
09/01/2010 08/31/2012<br />
09/01/2010 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2009 12/31/2009
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 255 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2569<br />
RECOVERY NETWORK<br />
STERLON WHITE<br />
1314 W NATIONAL AVENUE<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 727-7985<br />
Fax: (414) 727-8121<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/16/2004<br />
01/01/2010<br />
12/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1779<br />
RECOVERY-WORKS COUNSELING SERVICES, INC.<br />
DAVID SCHREITER<br />
635 PINE STREET<br />
GREEN BAY, WI 54301<br />
County: Brown<br />
recoveryworks1@sbcglobal.net<br />
Phone: (920) 430-7401<br />
Fax: (920) 437-3197<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/05/2005<br />
08/01/2011<br />
07/31/2012<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1781<br />
RED CLIFF AODA PROGRAM/MISHOMIS HOUSE<br />
MARTIN GORDON<br />
37390 N BRADUM ROAD<br />
BAYFIELD, WI 54814<br />
County: Bayfield<br />
magordon@redcliff-nsn.gov<br />
Phone: (715) 779-3741<br />
Fax: (715) 779-3765<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/26/2010 07/31/2011<br />
01/01/2010 12/31/2011<br />
01/01/2010 12/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1983<br />
10/01/2012<br />
09/30/2014<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2012 09/30/2014<br />
10/01/2012 09/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 256 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1783<br />
RED CLIFF MENTAL HEALTH PROGRAM<br />
JACOB GEISLER<br />
88455 PIKE ROAD<br />
BAYFIELD, WI 54814<br />
County: Bayfield<br />
jgeisler@redcliff-nsn.gov<br />
Phone: (715) 779-3707<br />
Fax: (715) 779-3777<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1983<br />
10/01/2009<br />
09/30/2010<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2514<br />
RED OAK COUNSELING<br />
ROXANNE M. GUENTHER<br />
12970 W BLUEMOUND ROAD, #308<br />
ELM GROVE, WI 53122<br />
County: Waukesha<br />
roxanne@redoakcounsel<strong>in</strong>g.com<br />
Phone: (262) 780-1020<br />
Fax: (262) 780-1022<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2004<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1786<br />
REGENT MENTAL HEALTH GROUP<br />
CHRISTINE MOLZAHN<br />
6515 WATTS ROAD, #206<br />
MADISON, WI 53719<br />
County: Dane<br />
No Email Address Provided<br />
Phone: (608) 238-5826<br />
Fax: (608) 238-1221<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2009 09/30/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1979<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2010 08/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 257 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2919<br />
RELEVANCE COUNSELING SERVICES<br />
ROSIE MALDONADO<br />
3635 W OKLAHOMA AVENUE<br />
MILWAUKEE, WI 53215<br />
County: Milwaukee<br />
relevancecounsel<strong>in</strong>gservices@juno.com<br />
Phone: (414) 384-6777<br />
Fax: (414) 384-8001<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/29/2010<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1792<br />
RENEW COUNSELING SERVICES<br />
WAYNE CROATT<br />
1225 W. MITCHELL STREET, #223<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
renewcounsel<strong>in</strong>g1@sbcglobal.net<br />
Phone: (414) 383-4455<br />
Fax: (414) 433-0171<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1985<br />
09/01/2011<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1797<br />
RICHLAND COUNTY HEALTH & HUMAN SERVICES<br />
TRACY THORSEN<br />
221 W SEMINARY STREET<br />
RICHLAND CENTER, WI 53581<br />
County: Richl<strong>and</strong><br />
thorsent@co.richl<strong>and</strong>.wi.us<br />
Phone: (608) 647-8821<br />
Fax: (608) 647-6611<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1988<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
09/01/2011 08/31/2012<br />
09/01/2011 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 258 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2563<br />
RICHLAND COUNTY HEALTH AND HUMAN<br />
SERVICES COMPREHENSIVE COMMUNITY<br />
SERVICES<br />
TRACY THORSEN<br />
221 W SEMINARY STREET<br />
RICHLAND CENTER, WI 53581<br />
County: Richl<strong>and</strong><br />
thorsent@co.richl<strong>and</strong>.wi.us<br />
Phone: (608) 647-8821<br />
Fax: (608) 647-6611<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/2005<br />
01/01/2012<br />
12/31/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
1926<br />
RIDGEWOOD RECOVERY, INC. DBA THE<br />
SUPERIOR TREATMENT CENTER<br />
CHAD BRAAFLADT<br />
1507 TOWER AVENUE, #307<br />
SUPERIOR, WI 54880<br />
County: Douglas<br />
<strong>in</strong>fo@superiortreatmentcenter.org<br />
Phone: (715) 392-9300<br />
Fax: (715) 392-8041<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1997<br />
03/01/2011<br />
02/28/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1800<br />
RIVERSIDE COUNSELING, LLC<br />
No Contact Name Provided<br />
1575 E. ALLOUEZ AVENUE<br />
GREEN BAY, WI 54311<br />
County: Brown<br />
No Email Address Provided<br />
Phone: (920) 469-1155<br />
Fax: No Number Provided<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1995<br />
11/01/2004<br />
10/31/2005<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
03/01/2011 02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2004 10/31/2005
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 259 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2264<br />
RIVERSIDE PSYCHIATRIC GROUP, SC<br />
KAREN SCHULTZ<br />
1325 ANGELS PATH<br />
DE PERE, WI 54115<br />
County: Brown<br />
Karens@Riversidepsych.com<br />
Phone: (920) 338-2855<br />
Fax: (920) 338-9270<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/2000<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1802<br />
RIVERVIEW HOSPITAL ASSOCIATION<br />
COLLEEN KANE<br />
410 DEWEY STREET<br />
WISCONSIN RAPIDS, WI 54495<br />
County: Wood<br />
No Email Address Provided<br />
Phone: (715) 423-6060<br />
Fax: (715) 421-7512<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1986<br />
07/01/2012<br />
06/30/2014<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
2622<br />
RIVERVIEW PSYCHOTHERAPY<br />
LAURA PAGEL<br />
216 N WATER STREET, #2<br />
MILWAUKEE, WI 53202<br />
County: Milwaukee<br />
LLPisme@sbcglobal.net<br />
Phone: (414) 223-4000<br />
Fax: (414) 223-2660<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2005<br />
11/01/2008<br />
10/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2008 10/31/2010
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 260 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2230<br />
RIVERWOOD COUNSELING ASSOCIATES LLC<br />
ROBERT A MILLER<br />
1052 MAIN STREET, #202<br />
STEVENS POINT, WI 54481<br />
County: Portage<br />
riverwood_counsel<strong>in</strong>g@hotmail.com<br />
Phone: (715) 343-5256<br />
Fax: (715) 343-5899<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/17/2000<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1803<br />
ROCK COUNTY HUMAN SERVICES CRISIS<br />
INTERVENTION UNIT<br />
KATHERINE FLANAGAN<br />
3530 N. COUNTY HIGHWAY F<br />
JANESVILLE, WI 53547<br />
County: Rock<br />
RCHSD@co.rock.wi.us<br />
Phone: (608) 757-5025<br />
Fax: (608) 758-8426<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/10/1975<br />
09/01/2012<br />
08/31/2014<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Intervention DHS 75.16<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
1804<br />
ROCK COUNTY HUMAN SERVICES DEPARTMENT -<br />
BELOIT COMMUNITY SUPPORT PROGRAM<br />
PATRICK SINGER<br />
64 ECLIPSE CENTER<br />
BELOIT, WI 53511<br />
County: Rock<br />
s<strong>in</strong>ger@co.rock.wi.us<br />
Phone: (608) 757-5269<br />
Fax: (608) 363-6392<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1989<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 261 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1805<br />
ROCK COUNTY HUMAN SERVICES DEPARTMENT -<br />
JANESVILLE COMMUNITY SUPPORT PROGRAM<br />
LISA MOORE-KELTY<br />
113 S FRANKLIN ST<br />
JANESVILLE, WI 53548<br />
County: Rock<br />
Kelty@co.rock.wi.us<br />
Phone: (608) 757-5172<br />
Fax: (608) 757-5545<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1989<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1806<br />
ROCK COUNTY HUMAN SERVICES DEPARTMENT<br />
ADOLESCENT SERVICES CENTER<br />
TERA O'CONNOR<br />
3530 N COUNTY TRUNK HWY F<br />
JANESVILLE, WI 53545<br />
County: Rock<br />
RCHSD@co.rock.wi.us<br />
Phone: (608) 757-5378<br />
Fax: (608) 758-8435<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
09/01/2011<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1808<br />
ROCK COUNTY HUMAN SERVICES DEPARTMENT<br />
BELOIT COUNSELING CENTER<br />
KENT HUBBARD<br />
64 ECLIPSE CENTER<br />
BELOIT, WI 53511<br />
County: Rock<br />
RCHSD@co.rock.wi.us<br />
Phone: (608) 363-6300<br />
Fax: (608) 363-6392<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
09/01/2011<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
09/01/2011 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2011 08/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 262 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1807<br />
ROCK COUNTY HUMAN SERVICES DEPARTMENT<br />
JANESVILLE COUNSELING CENTER<br />
KENT HUBBARD<br />
113 S FRANKLIN STREET<br />
JANESVILLE, WI 53548<br />
County: Rock<br />
RCHSD@co.rock.wi.us<br />
Phone: (608) 757-5850<br />
Fax: (608) 758-5858<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1975<br />
09/01/2011<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2799<br />
ROCK VALLEY COMMUNITY PROGRAMS, INC.<br />
DBA BELOIT YOUTH PLACE<br />
EMMA HARRELL<br />
416 COLLEGE STREET, #A<br />
BELOIT, WI 53511<br />
County: Rock<br />
aeggers@rvcp.org<br />
Phone: (608) 365-0810<br />
Fax: (608) 365-0711<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/18/2008<br />
08/01/2011<br />
07/31/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1809<br />
ROCK VALLEY COMMUNITY PROGRAMS, INC.<br />
EMMA HARRELL<br />
203 W. SUNNY LANE ROAD<br />
JANESVILLE, WI 53546<br />
County: Rock<br />
eharrell@rvcp.org<br />
Phone: (608) 741-4500<br />
Fax: (608) 741-4502<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2011 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1990<br />
03/01/2012<br />
02/28/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2012 02/28/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 263 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2532<br />
ROGERS MEMORIAL HOSPITAL - CHILD &<br />
ADOLESCENT DAY TREATMENT<br />
KRISTINE KIM<br />
4600 SCHROEDER DRIVE<br />
BROWN DEER, WI 53223<br />
County: Milwaukee<br />
KKim@rogershospital.org<br />
Phone: (414) 355-9000<br />
Fax: (414) 355-9665<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/13/2004<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 2 DHS 40.11(2)(b)<br />
2070<br />
ROGERS MEMORIAL HOSPITAL - HERRINGTON<br />
RECOVERY CENTER<br />
CINDY SUSZEK<br />
34700 VALLEY ROAD<br />
OCONOMOWOC, WI 53066<br />
County: Waukesha<br />
csuszek@rogershospital.org<br />
Phone: (262) 646-1616<br />
Fax: (262) 646-3158<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1998<br />
06/01/2011<br />
05/31/2013<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
2920<br />
ROGERS MEMORIAL HOSPITAL - MADISON<br />
PARTIAL HOSPITALIZATION PROGRAM<br />
DAVID GEBAUER<br />
406 SCIENCE DRIVE, #110<br />
MADISON, WI 53711<br />
County: Dane<br />
DGebauer@rogershospital.org<br />
Phone: (608) 238-4411<br />
Fax: (608) 238-4412<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/13/2010<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Children 2 w/Telehealth DHS 40.11(2)(b)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 2 DHS 40.11(2)(b)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment with Telehealth DHS 61.75<br />
NO BRANCH LOCATIONS<br />
06/01/2011 05/31/2013<br />
06/01/2011 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 264 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2214<br />
ROGERS MEMORIAL HOSPITAL - MILWAUKEE<br />
KATHY LOTZ<br />
11101 W. LINCOLN AVENUE<br />
WEST ALLIS, WI 53227<br />
County: Milwaukee<br />
klotz@rogershospital.org<br />
Phone: (414) 327-3000<br />
Fax: (414) 327-6045<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/2000<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Medically Managed Inpatient Treatment DHS 75.10<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 2 DHS 40.11(2)(b)<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2433<br />
ROGERS MEMORIAL HOSPITAL CHILD AND<br />
ADOLESCENT DAY TREATMENT PROGRAM<br />
LAURA MIRHOSEINI, PSY D<br />
9916 - 75TH STREET<br />
KENOSHA, WI 53142<br />
County: Kenosha<br />
lmirhose<strong>in</strong>i@rogers.hospital.org<br />
Phone: (262) 942-4000<br />
Fax: (262) 942-7740<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/28/2003<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 2 DHS 40.11(2)(b)<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 265 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1810<br />
ROGERS MEMORIAL HOSPITAL<br />
KATHY LOTZ<br />
34700 VALLEY ROAD<br />
OCONOMOWOC, WI 53066<br />
County: Waukesha<br />
No Email Address Provided<br />
Phone: (800) 767-4411<br />
Fax: (262) 646-3158<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/01/1988<br />
11/01/2011<br />
10/31/2013<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Day Treatment with Telehealth DHS 75.12<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Medically Managed Inpatient Treatment DHS 75.10<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treat/Chldren 3 w/Telehealth DHS 40.11(2)(c)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 3 DHS 40.11(2)(c)<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment with Telehealth DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2691<br />
RUSK COUNTY HEALTH & HUMAN<br />
SERVICES/ACCESS, INC.<br />
TED EAST<br />
311 E MINER AVENUE<br />
LADYSMITH, WI 54848<br />
County: Rusk<br />
teast@ruskcounty.wi.us<br />
Phone: (715) 532-2247<br />
Fax: (715) 532-2126<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/16/2006<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 266 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2947<br />
SACRED HEART BEHAVIORAL HEALTH CLINIC<br />
KIM JOHNSON<br />
4235 SOUTHTOWNE DRIVE<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
kjohnson@shec.hshs.org<br />
Phone: (715) 717-5899<br />
Fax: (715) 717-5898<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/31/2011<br />
10/31/2011<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2029<br />
SACRED HEART HOSPITAL<br />
THERESA MACKEY<br />
900 W. CLAIREMONT AVENUE<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
tmackey@shec.hshs.org<br />
Phone: (715) 717-4121<br />
Fax: (715) 717-5898<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
SACRED HEART HOSPITAL Tier 1<br />
900 W. CLAIREMONT AVENUE<br />
10/31/2011<br />
EAU CLAIRE, WI 54701<br />
09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1982<br />
01/01/2011<br />
12/31/2012<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2793<br />
SAFE HAVEN COUNSELING<br />
PAMELA OLSON<br />
548 N LAKE AVENUE<br />
PHILLIPS, WI 54555<br />
County: Price<br />
safehaven@pctcnet.net<br />
Phone: (715) 339-6453<br />
Fax: (715) 339-6450<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/31/2011 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2008<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
SAFE HAVEN COUNSELING Tier 1<br />
219 W 2ND STREET NORTH<br />
05/01/2011<br />
LADYSMITH, WI 54848<br />
04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 267 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1471<br />
SAINT MARY'S HOSPITAL KOLLER BEHAVIORAL<br />
HEALTH<br />
CHAD MCGRATH<br />
1020 KABEL AVENUE<br />
RHINELANDER, WI 54501<br />
County: Oneida<br />
No Email Address Provided<br />
Phone: (715) 369-2210<br />
Fax: (715) 361-2920<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/01/1978<br />
10/01/2009<br />
04/30/2011<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1820<br />
SAINT MICHAEL'S HOSPITAL<br />
LAURIE ROBERTS<br />
900 ILLINOIS AVENUE<br />
STEVENS POINT, WI 54481<br />
County: Portage<br />
No Email Address Provided<br />
Phone: (715) 346-5400<br />
Fax: (715) 346-5571<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1978<br />
10/01/2011<br />
09/30/2013<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
1822<br />
SAMARITAN COUNSELING CENTER OF<br />
SOUTHERN WISCONSIN<br />
DAN FEASTER<br />
5900 MONONA DRIVE #100<br />
MADISON, WI 53716<br />
County: Dane<br />
dfeaster@aol.com<br />
Phone: (608) 663-0763<br />
Fax: (608) 663-0765<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2009 04/30/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1994<br />
08/01/2012<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
SAMARITAN COUNSELING CENTER OF<br />
SOUTHERN WISCONSIN<br />
109 FIRST STREET<br />
LODI, WI 53555<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
Tier 1<br />
08/01/2012<br />
07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 07/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 268 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2755<br />
SANDERSON'S AODA SERVICES<br />
MICHAEL SANDERSON<br />
104 S EYDER #216<br />
PHILLIPS, WI 54555<br />
County: Price<br />
s<strong>and</strong>ersonaoda@yahoo.com<br />
Phone: (715) 456-4025<br />
Fax: (715) 339-4018<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/2007<br />
11/01/2010<br />
08/31/2012<br />
CSAS-Intervention DHS 75.16<br />
2713<br />
SAUK COUNTY DEPARTMENT OF HUMAN<br />
SERVICES COMPREHENSIVE COMMUNITY<br />
SERVICES<br />
SHARON BOESL<br />
505 BROADWAY<br />
BARABOO, WI 53913<br />
County: Sauk<br />
SBoesl@co.sauk.wi.us<br />
Phone: (608) 355-4200<br />
Fax: (608) 355-4299<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2007<br />
03/01/2011<br />
02/28/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
1824<br />
SAUK COUNTY DEPARMENT OF HUMAN<br />
SERVICES<br />
SHARON BOESL<br />
505 BROADWAY STREET<br />
BARABOO, WI 53913<br />
County: Sauk<br />
sboesl@co.sauk.wi.us<br />
Phone: (608) 355-4200<br />
Fax: (608) 355-4299<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2010 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1988<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 w/Telehealth DHS 34.3<br />
SAUK COUNTY DHS - REEDSBURG<br />
OFFICE<br />
425 SIXTH STREET<br />
REEDSBURG, WI 53959<br />
03/01/2011 02/28/2013<br />
Tier 2<br />
01/01/2012<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 269 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1823<br />
SAUK COUNTY DEPARTMENT OF HUMAN<br />
SERVICES COMMUNITY SUPPORT PROGRAM<br />
EDDIE SCANLAN<br />
425 SIXTH STREET<br />
REEDSBURG, WI 53959<br />
County: Sauk<br />
escanlan@co.sauk.wi.us<br />
Phone: (608) 355-4200<br />
Fax: (608) 524-7924<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1990<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1825<br />
SAWYER COUNTY HEALTH & HUMAN<br />
SERVICES/INFORMATION & REFERRAL CENTER<br />
JOE BODO<br />
10610 MAIN ST SUITE 224<br />
HAYWARD, WI 54843<br />
County: Sawyer<br />
jbodo@sawyerhs.hayward.wi.us<br />
Phone: (715) 634-4806<br />
Fax: (715) 634-3580<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1979<br />
07/01/2012<br />
06/30/2014<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
2804<br />
SCENIC BLUFFS COMMUNITY HEALTH CENTERS<br />
BARBARA MASHAK<br />
238 FRONT STREET<br />
CASHTON, WI 54619<br />
County: Monroe<br />
bmashak@scenicbluffs.org<br />
Phone: (608) 654-5100<br />
Fax: (608) 654-5120<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/28/2008<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 270 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1826<br />
SCHWERT AODA TREATMENT CENTER<br />
TODD VIETH<br />
3501 KIPLING DRIVE<br />
MADISON, WI 53704<br />
County: Dane<br />
tvieth@correctionalservices.org<br />
Phone: (608) 249-6226<br />
Fax: (608) 249-1954<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1992<br />
07/01/2011<br />
06/30/2013<br />
CSAS-Transitional Residential DHS 75.14<br />
2495<br />
SEBASTIAN FAMILY PSYCHOLOGY PRACTICE,<br />
LLC<br />
SEBASTIAN SSEMPIJJA<br />
1720 W FLORIST AVENUE, #125<br />
MILWAUKEE, WI 53209<br />
County: Milwaukee<br />
sseba4u@aol.com<br />
Phone: (414) 247-0801<br />
Fax: (414) 247-0816<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/14/2004<br />
03/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2242<br />
SHAWANO COUNTY DEPARTMENT OF<br />
COMMUNITY PROGRAMS COMMUNITY SUPPORT<br />
PROGRAM<br />
JOANN LISKA<br />
504 LAKELAND ROAD<br />
SHAWANO, WI 54166<br />
County: Shawano<br />
joann.liska@co.shawano.wi.us<br />
Phone: (715) 524-6888<br />
Fax: (715) 526-5542<br />
Surveyor: Frank Bellaire<br />
Services<br />
07/01/2011 06/30/2013<br />
SEBASTIAN FAMILY PSYCHOLOGY Tier 1<br />
1501 SOUTH LAYTON BLVD<br />
01/01/2012<br />
MILWAUKEE, WI 53215<br />
12/31/2012<br />
SEBASTIAN FAMILY PSYCHOLOGY Tier 1<br />
2463 NORTH BUFFUM STREET<br />
01/01/2012<br />
MILWAUKEE, WI 53212<br />
12/31/2012<br />
SEBASTIAN FAMILY PSYCHOLOGY Tier 1<br />
3300 SOUTH 39TH STREET<br />
01/01/2012<br />
MILWAUKEE, WI 53215<br />
12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2000<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
03/01/2011 12/31/2012<br />
03/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2011 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 271 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1831<br />
SHAWANO COUNTY DEPARTMENT OF<br />
COMMUNITY PROGRAMS<br />
JOANN LISKA<br />
504 LAKELAND ROAD<br />
SHAWANO, WI 54166<br />
County: Shawano<br />
joann.liska@co.shawano.wi.us<br />
Phone: (715) 524-6888<br />
Fax: (715) 526-5542<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1977<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Emergency Outpatent with Telehealth DHS 75.05<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 w/Telehealth DHS 34.3<br />
1832<br />
SHAWANO MEDICAL CENTER<br />
PENNY BLOCK<br />
309 N. BARTLETT STREET<br />
SHAWANO, WI 54166<br />
County: Shawano<br />
pblock@shawanomed.org<br />
Phone: (715) 526-7210<br />
Fax: (715) 526-7205<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1978<br />
04/01/2011<br />
03/31/2013<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
2315<br />
SHEBOYGAN COUNTY DEPARTMENT OF HEALTH<br />
AND HUMAN SERVICES CSP<br />
ERIC BRUNNICH<br />
1011 N. 8TH STREET<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
brunneb@co.sheboygan.wi.us<br />
Phone: (920) 459-3199<br />
Fax: (920) 459-4353<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1996<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 272 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1834<br />
SHEBOYGAN COUNTY DEPARTMENT OF HEALTH<br />
AND HUMAN SERVICES<br />
JODY A GALLAWAY, PSYD<br />
1011 N. 8TH STREET<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
humsrv@co.sheboygan.wi.us<br />
Phone: (920) 459-3155<br />
Fax: (920) 459-4353<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1986<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2667<br />
SHEBOYGAN COUNTY HEALTH & HUMAN<br />
SERVICES COMPREHENSIVE COMMUNITY<br />
SERVICES<br />
AMY CULVER<br />
1011 N 8TH STREET<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
culveajc@co.sheboygan.wi.us<br />
Phone: (920) 459-3171<br />
Fax: (920) 459-4353<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2006<br />
06/01/2012<br />
05/31/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
2945<br />
SHECAR SUBSTANCE ABUSE/MENTAL HEALTH<br />
OUTPATIENT TREATMENT CENTER, LLC<br />
SHEILA R RAMOS<br />
2821 N 4TH STREET, #308<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
shecar02@yahoo.com<br />
Phone: (414) 372-3903<br />
Fax: (414) 372-3964<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/27/2011<br />
07/01/2012<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
06/01/2012 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 08/31/2012<br />
07/01/2012 08/31/2012<br />
07/01/2012 08/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 273 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2582<br />
SHERMAN CONSULTING OSHKOSH<br />
HANK SHERMAN, PHD<br />
2370 STATE ROAD 44, #D<br />
OSHKOSH, WI 54904<br />
County: W<strong>in</strong>nebago<br />
shermanconsult<strong>in</strong>gllc@yahoo.com<br />
Phone: (920) 230-2065<br />
Fax: (920) 230-6565<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/03/2005<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2450<br />
SHERMAN CONSULTING, LLC<br />
HANK SHERMAN, PH.D.<br />
W6144 AREOTECH DRIVE<br />
APPLETON, WI 54913<br />
County: Outagamie<br />
shermanconsult<strong>in</strong>gllc@yahoo.com<br />
Phone: (920) 230-2065<br />
Fax: (920) 230-6565<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/05/2003<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2261<br />
SHERYL A. VAN HAREN, MSW<br />
SHERYL A VAN HAREN<br />
7635 W. BLUEMOUND ROAD, #206<br />
WAUWATOSA, WI 53213<br />
County: Milwaukee<br />
svanharen@sbcglobal.net<br />
Phone: (414) 479-9779<br />
Fax: (414) 479-9775<br />
Surveyor: Demetrius Anderson<br />
Services<br />
04/01/2012 03/31/2014<br />
SHERMAN CONSULTING, LLC Tier 1<br />
1825 S WEBSTER AVENUE STE 203<br />
06/01/2012<br />
GREEN BAY, WI 54301<br />
05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/28/2000<br />
10/01/2007<br />
09/30/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
06/01/2012 05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2007 09/30/2009
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 274 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2501<br />
SHORE COUNSELING AND CONSULTING CLINIC<br />
THOMAS TROAST<br />
2600 N MAYFAIR ROAD, #650<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
drtroast@wi.rr.com<br />
Phone: (414) 771-9304<br />
Fax: (414) 771-9543<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/24/2003<br />
02/01/2011<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1836<br />
SHOREHAVEN BEHAVIORAL HEALTH, INC<br />
LYNN GODEC<br />
3900 W. BROWN DEER ROAD, #200<br />
GLENDALE, WI 53209<br />
County: Milwaukee<br />
lgodec@shorehavenbhi.com<br />
Phone: (414) 540-2170<br />
Fax: (414) 540-2171<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
SHORE COUNSELING AND CONSULTING<br />
CLINIC<br />
6110 N PORT WASHINGTON ROAD<br />
GLENDALE, WI 53217<br />
Tier 1<br />
02/01/2011<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1983<br />
07/01/2012<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1838<br />
SILVER SPRING PSYCHOTHERAPY ASSOCIATES<br />
MARY ANN MITCHELL<br />
5215 N IRONWOOD ROAD, #115<br />
MILWAUKEE, WI 53217<br />
County: Milwaukee<br />
mitchellsspa@gmail.com<br />
Phone: (262) 821-7027<br />
Fax: (414) 332-0855<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
SHOREHAVEN BEHAVIORAL HEALTH,<br />
INC<br />
8405 W FOREST HOME, #104<br />
GREENFIELD, WI 53228<br />
02/01/2011 11/30/2012<br />
Tier 2<br />
07/01/2012<br />
12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1993<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
07/01/2012 12/31/2012<br />
07/01/2012 12/31/2012<br />
07/01/2012 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 275 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2506<br />
SOAR COUNSELING SERVICES<br />
CHERI KREITZMANN<br />
246 INDUSTRIAL DRIVE<br />
SHELL LAKE, WI 54871<br />
County: Washburn<br />
kreitzmannco@gmail.com<br />
Phone: (307) 250-1338<br />
Fax: (715) 468-2374<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/11/2004<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2373<br />
SOCIAL DEVELOPMENT COMMISSION YOUTH &<br />
FAMILY DEVELOPMENT PROGRAM<br />
PRISCILLA WALLACE<br />
4041 N. RICHARDS STREET<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
Pwallace@cr-sdc.org<br />
Phone: (414) 906-2711<br />
Fax: (414) 963-2691<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
SOAR COUNSELING SERVICES Tier 2<br />
517 BEASER AVENUE<br />
04/01/2012<br />
ASHLAND, WI 54806<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/29/2002<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2194<br />
SOKAOGON CHIPPEWA HEALTH CLINIC<br />
PAULETTE SMITH<br />
3144 VAN ZILE ROAD<br />
CRANDON, WI 54520<br />
County: Forest<br />
wgc567@yahoo.com<br />
Phone: (715) 478-5180<br />
Fax: (715) 478-5904<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/28/2000<br />
01/01/2012<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2012<br />
01/01/2012 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 276 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2679<br />
SONAS BEHAVIORAL HEALTH, LLC<br />
DELORES KLUPPEL VETTER<br />
6402 ODANA<br />
MADISON, WI 53719<br />
County: Dane<br />
dkvetter@charter.net<br />
Phone: (608) 204-6076<br />
Fax: (608) 204-9568<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/26/2006<br />
09/15/2009<br />
06/30/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1841<br />
SOUTH STREET CLINIC<br />
ANNE A WESTON, PHD<br />
416 SOUTH STREET<br />
OCONOMOWOC, WI 53066<br />
County: Waukesha<br />
s_cl<strong>in</strong>ic@hotmail.com<br />
Phone: (262) 567-7673<br />
Fax: (262) 567-3097<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1984<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2197<br />
SOUTHWEST HEALTH CENTER SENIOR<br />
BEHAVIORAL SCIENCE<br />
JOYCE GRAVES<br />
1185 NORTH ELM STREET<br />
PLATTEVILLE, WI 53818<br />
County: Grant<br />
GravesJ@southwesthealth.org<br />
Phone: (608) 348-3656<br />
Fax: (608) 342-3025<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/15/2009 06/30/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2000<br />
03/01/2012<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
NO BRANCH LOCATIONS<br />
06/01/2012 05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2012 02/28/2013<br />
03/01/2012 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 277 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2907<br />
SPADE'S COUNSELING AGENCY<br />
DIANE E SPADE<br />
908 - SECOND STREET<br />
MENOMINEE, MI 49858<br />
County/State: Menom<strong>in</strong>ee, MI<br />
dianespade@spadescounsel<strong>in</strong>g.com<br />
Phone: (906) 864-9830<br />
Fax: (906) 864-9831<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/07/2010<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2355<br />
SPANISH SPEAKING COUNSELING SERVICES<br />
JAVIER CADENA<br />
1118 W VETERANS STREET<br />
TOMAH, WI 54660<br />
County: Monroe<br />
blkwlf48@yahoo.com<br />
Phone: (608) 547-1209<br />
Fax: (608) 374-5567<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
SPADE'S COUNSELING AGENCY Tier 1<br />
1651 LUDINGTON STREET, #B<br />
08/01/2012<br />
MARINETTE, WI 54143<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/10/2012<br />
08/01/2012<br />
07/31/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1847<br />
ST AGNES HOSPITAL BEHAVIORAL HEALTH<br />
SERVICES<br />
JAMES SALASEK PHD<br />
430 E. DIVISION STREET<br />
FOND DU LAC, WI 54935<br />
County: Fond Du Lac<br />
salesekJ@agnesian.com<br />
Phone: (920) 926-4200<br />
Fax: (920) 926-8933<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1980<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Medically Managed Inpatient Treatment DHS 75.10<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Transitional Residential DHS 75.14<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
08/01/2012 07/31/2014<br />
ST AGNES HOSPITAL BEHAV HLTH Tier 2<br />
790 EASTGATE DRIVE<br />
01/01/2012<br />
RIPON, WI 54971<br />
12/31/2013<br />
ST AGNES HOSPITAL BEHAVIORAL<br />
HEALTH SVS<br />
Tier 1<br />
620 W BROWN STREET<br />
01/01/2012<br />
WAUPUN, WI 53963<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 278 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1322<br />
ST CHARLES YOUTH & FAMILY SERVICES -<br />
FAMILY DEVELOPMENT CENTER<br />
GLYNIS UNDERWOOD<br />
4757 N. 76TH STREET<br />
MILWAUKEE, WI 53218<br />
County: Milwaukee<br />
referrals@stcharles<strong>in</strong>c.org<br />
Phone: (414) 358-4173<br />
Fax: (414) 358-5005<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1991<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2860<br />
ST CHARLES YOUTH & FAMILY SERVICES INC,<br />
ODAYIN DAY TREATMENT<br />
SCOTT CARPENTER<br />
301 TROY DRIVE, COTTAGE A<br />
MADISON, WI 53704<br />
County: Dane<br />
cfrankl<strong>in</strong>@stcharles<strong>in</strong>c.org<br />
Phone: (608) 663-5910<br />
Fax: (608) 663-5912<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
ST CHARLES - FAMILY DEVELOP CTR Tier 1<br />
151 S 84TH STREET<br />
02/01/2011<br />
MILWAUKEE, WI 53214<br />
01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/19/2009<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 1 DHS 40.11(2)(a)<br />
1475<br />
ST JOSEPH'S HOSPITAL OF HOSP SISTERS OF ST<br />
FRANCIS DBA ST JOSEPH'S HOSPITAL<br />
THOMAS FUCHS<br />
2661 COUNTY TRUNK I<br />
CHIPPEWA FALLS, WI 54729<br />
County: Chippewa<br />
tfuchs@sjcf.hshs.org<br />
Phone: (715) 723-5585<br />
Fax: (715) 717-7504<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/12/1977<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Medically Managed Inpatient Treatment DHS 75.10<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
09/01/2010 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 279 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1846<br />
ST. AEMILIANS-LAKESIDE, INC.<br />
MICHAEL BOEDER<br />
8901 W. CAPITOL DRIVE<br />
MILWAUKEE, WI 53222<br />
County: Milwaukee<br />
mboeder@st-al.org<br />
Phone: (414) 463-1880<br />
Fax: (414) 463-2770<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1995<br />
09/01/2008<br />
08/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2156<br />
ST. CHARLES YOUTH AND FAMILY SERVICES<br />
CRAIG HUBBS<br />
9201 WATERTOWN PLANK RD<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
chubbs@stcharles<strong>in</strong>c.org<br />
Phone: (414) 476-3710<br />
Fax: (414) 778-5985<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1998<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 2 DHS 40.11(2)(b)<br />
2087<br />
ST. CLARE CENTER, ST. CLARE HOSPITAL<br />
JUDY HANNAFORD<br />
1510 JEFFERSON STREET<br />
BARABOO, WI 53913<br />
County: Sauk<br />
Judy_Hannaford@ssmhc.com<br />
Phone: (608) 356-1533<br />
Fax: (608) 356-1365<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2008 08/31/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/25/1998<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 280 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2586<br />
ST. CLARE HOSPITAL & HEALTH SERVICES<br />
ALICE FACEY<br />
707 - 14TH STREET<br />
BARABOO, WI 53913<br />
County: Sauk<br />
No Email Address Provided<br />
Phone: (608) 356-1400<br />
Fax: (608) 356-1367<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/2004<br />
04/01/2011<br />
03/31/2012<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
1856<br />
ST. CROIX COUNTY HEALTH & HUMAN SERVICES<br />
KATHY HUSTON<br />
1445 NORTH 4TH STREET<br />
NEW RICHMOND, WI 54017<br />
County: Sa<strong>in</strong>t Croix<br />
kathyh@co.sa<strong>in</strong>t-croix.wi.us<br />
Phone: (715) 246-8204<br />
Fax: (715) 246-8461<br />
Surveyor: Polly Wong<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1990<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1855<br />
ST. CROIX COUNTY HEALTH AND HUMAN<br />
SERVICES BEHAVIORAL HEALTH<br />
STEVE KIRT<br />
1445 N. 4TH STREET<br />
NEW RICHMOND, WI 54017<br />
County: Sa<strong>in</strong>t Croix<br />
stevek@co.sa<strong>in</strong>t-croix.wi.us<br />
Phone: (715) 246-8256<br />
Fax: (715) 246-8284<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 281 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2217<br />
ST. CROIX TRIBAL BEHAVIORAL HEALTH CLINIC<br />
SARAH CORMELL<br />
4404 STATE RD 70<br />
WEBSTER, WI 54893<br />
County: Burnett<br />
sarahc@stcroixtribalcenter.com<br />
Phone: (715) 349-8554<br />
Fax: (715) 349-8528<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/2000<br />
10/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1860<br />
ST. ELIZABETH HOSPITAL<br />
STEVIE REICH<br />
1506 S. ONEIDA STREET<br />
APPLETON, WI 54915<br />
County: Outagamie<br />
No Email Address Provided<br />
Phone: (920) 738-2930<br />
Fax: (920) 730-5480<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
ROUND LAKE CLINIC Tier 1<br />
2230 - 60TH AVENUE<br />
10/01/2011<br />
LUCK, WI 54853<br />
04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1984<br />
11/01/2011<br />
10/31/2013<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 3 DHS 40.11(2)(c)<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
NO BRANCH LOCATIONS<br />
10/01/2011 04/30/2013<br />
10/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 282 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1568<br />
ST. JOSEPH'S HOSPITAL ALCOHOL AND DRUG<br />
RECOVERY SERVICES<br />
SHEILA WEIX<br />
611 ST. JOSEPH'S AVENUE<br />
MARSHFIELD, WI 54449<br />
County: Wood<br />
Sheila.weix@m<strong>in</strong>istryhealth.org<br />
Phone: (715) 387-9700<br />
Fax: (715) 387-9519<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/02/1994<br />
12/01/2010<br />
11/30/2012<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Medically Managed Inpatient Treatment DHS 75.10<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1865<br />
ST. LUKE'S HOSPITAL<br />
KATHLEEN FOREMAN<br />
915 E. FIRST STREET<br />
DULUTH, MN 55805<br />
County/State: Sa<strong>in</strong>t Louis, MN<br />
No Email Address Provided<br />
Phone: (218) 249-5555<br />
Fax: (218) 249-2457<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1995<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2690<br />
ST. LUKE'S MEDICAL CENTER OUTPATIENT<br />
BEHAVIORAL HEALTH CLINIC<br />
KATHLEEN CONNELLY<br />
2900 W OKLAHOMA AVENUE<br />
MILWAUKEE, WI 53215<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 489-4094<br />
Fax: (414) 454-6450<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/30/2006<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 283 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1872<br />
ST. MARYS HOSPITAL MEDICAL CENTER<br />
LAUREN PALLIN<br />
700 S. PARK STREET<br />
MADISON, WI 53715<br />
County: Dane<br />
Lauren_E_Pall<strong>in</strong>@ssmhc.com<br />
Phone: (608) 258-6697<br />
Fax: (608) 259-5317<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/1983<br />
06/01/2010<br />
05/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2515<br />
ST. MARY'S HOSPITAL MINISTRY BEHAVIORAL<br />
HEALTH INPATIENT<br />
ANDREA STEFONEK<br />
2251 N. SHORE DRIVE, #100<br />
RHINELANDER, WI 54501<br />
County: Oneida<br />
<strong>and</strong>rea.stefoneck@m<strong>in</strong>istryheatlh.org<br />
Phone: (715) 361-2020<br />
Fax: (715) 361-2021<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2004<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
NO BRANCH LOCATIONS<br />
06/01/2010 05/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 284 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1762<br />
ST. MARY'S HOSPITAL MINISTRY KOLLER<br />
BEHAVIORAL HEALTH<br />
ANDREA STEFONEK<br />
1020 KABEL AVENUE<br />
RHINELANDER, WI 54501<br />
County: Oneida<br />
<strong>and</strong>rea.stefonek@m<strong>in</strong>istryhealth.org<br />
Phone: (715) 361-2805<br />
Fax: (715) 361-2920<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/1985<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1876<br />
ST. ROSE YOUTH & FAMILY CENTER<br />
KARIE L. LOWE<br />
3801 N. 88TH STREET<br />
MILWAUKEE, WI 53222<br />
County: Milwaukee<br />
karielowe@ladlake.org<br />
Phone: (414) 466-9450<br />
Fax: (414) 466-0730<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
ST MARYS HOSP MINISTRY/KOLLER<br />
CRANDON<br />
400 W GLEN STREET<br />
CRANDON, WI 54520<br />
ST MARYS HOSP MINISTRY/KOLLER<br />
EAGLE RIVER<br />
930 E WALL STREET<br />
EAGLE RIVER, WI 54521<br />
ST MARYS HOSP MINISTRY/KOLLER<br />
TOMAHAWK<br />
401 MOHAWK AVE<br />
TOMAHAWK, WI 54487<br />
ST MARYS HOSP MINISTRY/KOLLER<br />
WOODRUFF<br />
311 ELM STREET<br />
WOODRUFF, WI 54568<br />
Tier 1<br />
06/01/2012<br />
05/31/2014<br />
Tier 1<br />
06/01/2012<br />
05/31/2014<br />
Tier 1<br />
06/01/2012<br />
05/31/2014<br />
Tier 2<br />
06/01/2012<br />
05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/05/1985<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
06/01/2012 05/31/2014<br />
06/01/2012 05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2010 08/31/2012<br />
09/01/2010 08/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 285 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2467<br />
STEIN COUNSELING AND CONSULTING<br />
SERVICES, LTD<br />
TED STEIN<br />
571 BRAUND STREET<br />
LA CROSSE, WI 54601<br />
County: La Crosse<br />
tste<strong>in</strong>@effectivebehavior.com<br />
Phone: (608) 785-7000<br />
Fax: (608) 785-7477<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/06/2003<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1879<br />
STEP 3 COUNSELING, LLC<br />
KIM JAEGER<br />
117 W. SOUTH STREET<br />
OCONOMOWOC, WI 53066<br />
County: Waukesha<br />
No Email Address Provided<br />
Phone: (262) 567-5180<br />
Fax: (262) 560-1770<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
STEIN COUNSELING & CONSULTING<br />
SERVICES, LTD<br />
Tier 1<br />
20873 COLLEGE AVENUE<br />
09/01/2011<br />
GALESVILLE, WI 54630<br />
08/31/2013<br />
STEIN COUNSELING & CONSULTING<br />
SERVICES, LTD<br />
Tier 1<br />
ONALASKA HIGH SCHOOL, 700 HILLTOPPER 02/27/2012<br />
ONALASKA, WI 54650<br />
08/31/2013<br />
STEIN COUNSELING & CONSULTING<br />
SERVICES, LTD<br />
Tier 2<br />
505 KING STREET, #128<br />
09/01/2011<br />
LA CROSSE, WI 54601<br />
08/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1992<br />
01/01/2008<br />
12/31/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2596<br />
STEPPING STONES COUNSELING CENTER, LLC<br />
DIANE LONDON<br />
219 ROSS AVENUE<br />
SCHOFIELD, WI 54476<br />
County: Marathon<br />
DianeLLondon@aol.com<br />
Phone: (715) 355-4999<br />
Fax: (715) 355-5999<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2011 08/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/16/2005<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
01/01/2008 12/31/2009<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2014<br />
05/01/2012 04/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 286 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1881<br />
STILLWATER COUNSELING CENTER<br />
HELEN PONEC<br />
933 N MAYFAIR ROAD, #303<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 456-9929<br />
Fax: (414) 456-9994<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/01/1996<br />
02/01/2010<br />
01/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1882<br />
STOCKBRIDGE-MUNSEE HEALTH AND WELLNESS<br />
CENTER<br />
LYDIA VITORIT<br />
W12802 COUNTY ROAD A<br />
BOWLER, WI 54416<br />
County: Shawano<br />
lydia.vitorit@mohican.com<br />
Phone: (715) 793-3000<br />
Fax: (715) 793-1312<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1984<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
1883<br />
STOUGHTON FAMILY COUNSELING SERVICES<br />
LLC<br />
PATRICIA RENAULT<br />
1520 VERNON STREET<br />
STOUGHTON, WI 53589<br />
County: Dane<br />
sfcs01@gmail.com<br />
Phone: (608) 873-6422<br />
Fax: (608) 873-6014<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2010 01/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1980<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 287 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1884<br />
STOUGHTON HOSPITAL<br />
HEATHER KLEINBROOK<br />
900 RIDGE STREET<br />
STOUGHTON, WI 53589<br />
County: Dane<br />
hkle<strong>in</strong>brook@stohosp.com<br />
Phone: (608) 873-2242<br />
Fax: (608) 873-2339<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/01/1997<br />
09/01/2012<br />
08/31/2014<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
1887<br />
STRESS MANAGEMENT & MENTAL HEALTH<br />
CLINICS, INC.<br />
PAUL GLASS<br />
2717 N. GRANDVIEW BLVD., #303<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
waukesha@stressmanagementcl<strong>in</strong>ic.com<br />
Phone: (262) 544-6486<br />
Fax: (262) 544-6377<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1990<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1886<br />
STRESS MANAGEMENT & MENTAL HEALTH<br />
CLINICS<br />
DR CRAIG MODELL<br />
5225 N. IRONWOOD LANE, #102<br />
GLENDALE, WI 53217<br />
County: Milwaukee<br />
No Email Address Provided<br />
Phone: (414) 329-7000<br />
Fax: (414) 329-7010<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1997<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 288 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1885<br />
STRESS MANAGEMENT AND MENTAL HEALTH<br />
CLINICS<br />
CRAIG MODELL<br />
10201 W LINCOLN AVENUE, #308<br />
WEST ALLIS, WI 53227<br />
County: Milwaukee<br />
stressmang@hotmail.com<br />
Phone: (414) 329-7000<br />
Fax: (414) 329-7010<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/1980<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1889<br />
SUBURBAN COUNSELING SERVICES, LLC<br />
LAURA CAMPBELL PHD<br />
13965 W. BURLEIGH ROAD, # 103<br />
BROOKFIELD, WI 53005<br />
County: Waukesha<br />
drcampbell@suburbancounsel<strong>in</strong>g.com<br />
Phone: (414) 550-9350<br />
Fax: (262) 785-1409<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
STRESS MANAGEMENT & MENTAL<br />
HEALTH CLINICS<br />
N116 W16150 MAIN STREET<br />
GERMANTOWN, WI 53022<br />
Tier 1<br />
06/01/2011<br />
05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/1987<br />
10/15/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2751<br />
SUE HUBER & ASSOCIATES, SC<br />
SUE HUBER<br />
1039 W MASON STREET<br />
GREEN BAY, WI 54303<br />
County: Brown<br />
No Email Address Provided<br />
Phone: (920) 496-3130<br />
Fax: No Number Provided<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
06/01/2011 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/11/2007<br />
10/01/2008<br />
09/30/2009<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
10/15/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2008 09/30/2009
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 289 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2216<br />
SUE SITTLER NELSON, MSW PSYCHOTHERAPY<br />
ASSOCIATES<br />
SUE SITTLER NELSON<br />
316 N 96TH STREET, #302<br />
MILWAUKEE, WI 53202<br />
County: Milwaukee<br />
sue.sittler.nelson@aurora.org<br />
Phone: (414) 765-0665<br />
Fax: (414) 321-3519<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/14/2000<br />
05/01/2008<br />
04/30/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2238<br />
SUMMIT PSYCHOLOGY CLINIC, SC<br />
JEANNE HERZOG<br />
933 N. MAYFAIR ROAD, #303<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
dan@viewthesummit.com<br />
Phone: (414) 258-8488<br />
Fax: (414) 258-8838<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/24/2000<br />
09/01/2009<br />
08/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1408<br />
SYNERGY GROUP OF EAU CLAIRE, SC DBA HEINZ<br />
PSYCHOLOGICAL SERVICES, LTD., S.C.<br />
MARK BJERKE<br />
826 S. HASTINGS WAY<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
viv@he<strong>in</strong>zpsych.com<br />
Phone: (715) 834-3171<br />
Fax: (715) 834-3174<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2008 04/30/2010<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/1990<br />
09/01/2012<br />
08/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
SYNERGY OF EC, DBA HEINZ PSYCH<br />
SERVICES<br />
420 S BARSTOW STREET, #3<br />
EAU CLAIRE, WI 54701<br />
09/01/2009 08/31/2011<br />
Tier 2<br />
09/01/2012<br />
08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 290 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1898<br />
TAYLOR COUNTY HUMAN SERVICES<br />
DEPARTMENT<br />
AMBER FALLOS<br />
540 E. COLLEGE STREET<br />
MEDFORD, WI 54451<br />
County: Taylor<br />
amber.fallos@co.taylor.wi.us<br />
Phone: (715) 748-3332<br />
Fax: (715) 748-3342<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/1982<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1901<br />
TELLURIAN MCGOVERN OUTPATIENT CLINIC<br />
DAVE MACK<br />
5900 MONONA DRIVE, #300<br />
MONONA, WI 53716<br />
County: Dane<br />
dmack@tellurian.org<br />
Phone: (608) 442-4333<br />
Fax: (608) 223-3316<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/27/2011<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1900<br />
TELLURIAN UCAN, INC.<br />
SARAH LIM<br />
300 FEMRITE DRIVE<br />
MADISON, WI 53716<br />
County: Dane<br />
slim@tellurian.org<br />
Phone: (608) 222-7311<br />
Fax: (608) 222-0453<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1993<br />
06/01/2012<br />
05/31/2014<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 291 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1904<br />
TELLURIAN UCAN<br />
SARAH LIM<br />
2914 INDUSTRIAL DRIVE<br />
MADISON, WI 53713<br />
County: Dane<br />
slim@tellurian.org<br />
Phone: (608) 223-3311<br />
Fax: (608) 223-3304<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/01/1985<br />
11/01/2011<br />
10/31/2013<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Monitored Residential Detox DHS 75.07<br />
2921<br />
THE BRIDGE HEALTH CLINICS & RESEARCH<br />
CENTERS<br />
TODD CAMPBELL<br />
600 W VIRGINIA STREET, #203<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
toddcampbell@thebridgehealthcl<strong>in</strong>ics.com<br />
Phone: (414) 831-4500<br />
Fax: (414) 255-3451<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/19/2010<br />
08/01/2011<br />
07/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1908<br />
THE BROWNSTONE OFFICE OF NORTH SHORE<br />
PSYCHOTHERAPY ASSOCIATES<br />
EPHRAIM A CIRUZZI FRANKEL<br />
1110 OLD WORLD 3RD STREET, #410<br />
MILWAUKEE, WI 53203<br />
County: Milwaukee<br />
csuccess@execpc.com<br />
Phone: (414) 272-0223<br />
Fax: (414) 964-1915<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1996<br />
10/01/2010<br />
11/30/2010<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013<br />
08/01/2011 07/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2010 11/30/2010
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 292 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1123<br />
THE CAMBRIDGE GROUP<br />
PAUL SMERZ<br />
6110 N. PORT WASHINGTON ROAD<br />
GLENDALE, WI 53217<br />
County: Milwaukee<br />
PSmerz@aol.com<br />
Phone: (414) 332-7400<br />
Fax: (414) 963-6866<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/1990<br />
08/01/2010<br />
07/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1147<br />
THE CENTER FOR CHRISTIAN COUNSELING,<br />
CONSULTATION, AND TRAINING INC<br />
KEVIN RANDALL<br />
5310 WALL STREET, #500<br />
MADISON, WI 53718<br />
County: Dane<br />
No Email Address Provided<br />
Phone: (608) 274-8294<br />
Fax: (608) 274-8783<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1982<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1909<br />
THE CENTRE FOR WELL-BEING, INC.<br />
SHARON MUTTONEN<br />
300 N THIRD STREET, #302<br />
WAUSAU, WI 54403<br />
County: Marathon<br />
No Email Address Provided<br />
Phone: (715) 848-5022<br />
Fax: No Number Provided<br />
Surveyor: Bradley Jahr<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2010 07/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/17/1992<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
08/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2011 08/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 293 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1333<br />
THE COUNSELING CLINIC-FAMILY SERVICES OF<br />
NORTHEAST WISCONSIN, INC.<br />
LOIS MISCHLER<br />
1810 APPLETON ROAD<br />
MENASHA, WI 54952<br />
County: W<strong>in</strong>nebago<br />
syang@fmailyservicenew.org<br />
Phone: (920) 739-4226<br />
Fax: (920) 739-7639<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1983<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2038<br />
THE D & S HEALING CENTER<br />
TRACY TREACY<br />
3628 WEST WRIGHT ST<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
tracy@dsheal<strong>in</strong>gcenter.com<br />
Phone: (414) 265-0300<br />
Fax: (414) 265-0200<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/1998<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2857<br />
THE FAMILY CENTER<br />
BETTY RYGIEWICZ<br />
8025 EXCELSIOR DRIVE, #110<br />
MADISON, WI 53717<br />
County: Dane<br />
BRygiewicz@edgewood.edu<br />
Phone: (608) 663-6154<br />
Fax: (608) 664-9854<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/02/2009<br />
09/01/2012<br />
08/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
06/01/2011 05/31/2013<br />
06/01/2011 05/31/2013<br />
06/01/2011 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2012 08/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 294 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2523<br />
THE GILANE CENTER<br />
JOHN GILANE<br />
10144 N PORT WASHINGTON RD #LL-B<br />
MEQUON, WI 53092<br />
County: Ozaukee<br />
gilanecenter@sbcglobal.net<br />
Phone: (262) 240-1240<br />
Fax: (262) 240-1245<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/2004<br />
06/01/2011<br />
05/31/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2912<br />
THE GROWING TREE COUNSELING & WELLNESS,<br />
LLC<br />
AUDRA EGGUM<br />
140 W MAIN STREET, #A<br />
WINNECONNE, WI 54986<br />
County: W<strong>in</strong>nebago<br />
TheGrow<strong>in</strong>gTree@ymail.com<br />
Phone: (920) 582-4000<br />
Fax: (888) 845-9581<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/19/2010<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2634<br />
THE HUMAN DEVELOPMENT CENTER, INC.<br />
JAY PELDO<br />
5480 N 92ND ST<br />
MILWAUKEE, WI 53225<br />
County: Milwaukee<br />
jpeldo@humdevctr.org<br />
Phone: (414) 475-1321<br />
Fax: (414) 449-9912<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
06/01/2011 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/25/2006<br />
02/01/2012<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
06/01/2011 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2012 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 295 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1914<br />
THE INTEGRAL PSYCHOLOGY CENTER<br />
ARDEN MAHLBERG<br />
1619 MONROE ST<br />
MADISON, WI 53711<br />
County: Dane<br />
ipc@<strong>in</strong>tegralpsychology.com<br />
Phone: (608) 255-9330<br />
Fax: (608) 255-7810<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/1979<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2207<br />
THE KELLEY CLINIC<br />
JANE KELLEY<br />
1216 N. PROSPECT AVENUE<br />
MILWAUKEE, WI 53202<br />
County: Milwaukee<br />
jane@thekelleycl<strong>in</strong>ic.com<br />
Phone: (414) 271-9272<br />
Fax: (414) 271-1299<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1999<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2944<br />
THE POWER OF CHANGE INC BEHAVIORAL<br />
SERVICES<br />
RHONDA ARMON-BENT<br />
3975 N 68TH STREET<br />
MILWAUKEE, WI 53216<br />
County: Milwaukee<br />
thepowerofchange@gmail.com<br />
Phone: (414) 393-0922<br />
Fax: (414) 393-0928<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2012 04/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011<br />
07/01/2011<br />
06/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011 06/30/2012<br />
07/01/2011 06/30/2012<br />
07/01/2011 06/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 296 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1918<br />
THE PSYCHOLOGY CENTER, S.C.<br />
SUZANNE DRENNAN<br />
7617 MINERAL POINT ROAD, #300<br />
MADISON, WI 53717<br />
County: Dane<br />
sdrennan@tpcmadison.com<br />
Phone: (608) 833-9290<br />
Fax: (608) 833-9691<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1989<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1919<br />
THE PSYCHOLOGY CLINIC, INC.<br />
JAMES BLACK, PHD<br />
310 N. MIDVALE BOULEVARD, #202<br />
MADISON, WI 53705<br />
County: Dane<br />
jhblack@wisc.edu<br />
Phone: (608) 238-9991<br />
Fax: (608) 238-1929<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1991<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1920<br />
THE RAINBOW PROJECT, INC.<br />
SHARYL KATO<br />
831 E. WASHINGTON AVENUE<br />
MADISON, WI 53703<br />
County: Dane<br />
skato@thera<strong>in</strong>bowproject.net<br />
Phone: (608) 255-7356<br />
Fax: (608) 255-0457<br />
Surveyor: William Rohner<br />
Services<br />
12/01/2011 11/30/2013<br />
AIDS NETWORK Tier 1<br />
600 WILLIAMSON STREET<br />
11/01/2010<br />
MADISON, WI 53703<br />
10/31/2012<br />
THE PSYCHOLOGY CLINIC, INC -<br />
BARABOO<br />
Tier 2<br />
701 ASH STREET<br />
11/01/2010<br />
BARABOO, WI 53913<br />
10/31/2012<br />
THE PSYCHOLOGY CLINIC, INC -<br />
PRAIRIE DU SAC<br />
Tier 2<br />
1190 PRAIRIE STREET<br />
11/01/2010<br />
PRAIRIE DU SAC, WI 53578<br />
10/31/2012<br />
THE PSYCHOLOGY CLINIC, INC - WI<br />
DELLS<br />
Tier 1<br />
1000 HWY 13<br />
07/08/2011<br />
WISCONSIN DELLS, WI 53965<br />
10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1988<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2011 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 297 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2805<br />
THE REDI CLINIC - A DIVISION OF PATHWAY<br />
CLINIC, SC<br />
DAVID DRAJKOWSKI<br />
2300 N MAYFAIR ROAD, #425<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
ddrajkowski@pathwaycl<strong>in</strong>ic.com<br />
Phone: (414) 727-4455<br />
Fax: (414) 727-4690<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/09/2008<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
1355<br />
THE SAMARITAN COUNSELING CENTER OF THE<br />
FOX VALLEY<br />
ROSANGELA BERBERT<br />
1478 KENWOOD DRIVE STE 1<br />
MENASHA, WI 54952<br />
County: W<strong>in</strong>nebago<br />
rberbert@samaritan-counsel<strong>in</strong>g.com<br />
Phone: (920) 886-9319<br />
Fax: (920) 886-9357<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
THE REDI CLINIC - A DIVISION OF<br />
PATHWAY CLINIC<br />
402 N GENESEE STREET<br />
DELAFIELD, WI 53018<br />
Tier 2<br />
10/01/2011<br />
09/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1983<br />
03/01/2011<br />
02/28/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
PROJECT OPEN DOOR IMMANUEL<br />
UNITED CHURCH<br />
510 SULLIVAN AVENUE<br />
KAUKAUNA, WI 54130<br />
THE SAMARITAN COUNSELING CTR FOX<br />
VALLEY<br />
1478 MIDWAY ROAD<br />
MENASHA, WI 54952<br />
THE SAMARITAN COUNSELING CTR FOX<br />
VALLEY<br />
110 CHURCH AVENUE<br />
OSHKOSH, WI 54901<br />
THE SAMARITAN COUNSELING CTR FOX<br />
VALLEY<br />
709 W PINE STREET<br />
NEW LONDON, WI 54961<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
10/01/2011 09/30/2013<br />
Tier 1<br />
03/24/2011<br />
02/28/2013<br />
Tier 1<br />
03/01/2011<br />
02/28/2013<br />
Tier 2<br />
03/01/2011<br />
02/28/2013<br />
Tier 1<br />
03/01/2011<br />
02/28/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2011 02/28/2013<br />
03/01/2011 02/28/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 298 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1946<br />
THEDACARE BEHAVIORAL HEALTH AT THEDA<br />
CLARK MEDICAL CENTER<br />
BARBARA CONIFF<br />
130 SECOND STREET<br />
NEENAH, WI 54956<br />
County: W<strong>in</strong>nebago<br />
barbara.coniff@thedacare.org<br />
Phone: (920) 716-0462<br />
Fax: (920) 729-2906<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1983<br />
02/01/2011<br />
01/31/2013<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 299 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2052<br />
THEDACARE BEHAVIORAL HEALTH<br />
HEATHER PAYETTE<br />
1095 MIDWAY ROAD<br />
MENASHA, WI 54952<br />
County: W<strong>in</strong>nebago<br />
heather.payette@thedacare.org<br />
Phone: (920) 720-2300<br />
Fax: (920) 720-3719<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/31/1998<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
THEDACARE BEHAVIORAL HEALTH Tier 2<br />
401 S ELM ST<br />
07/01/2012<br />
APPLETON, WI 54911<br />
06/30/2014<br />
THEDACARE BEHAVIORAL HEALTH Tier 2<br />
3301-C NORTH BALLARD RD<br />
07/01/2012<br />
APPLETON, WI 54911<br />
06/30/2014<br />
THEDACARE BEHAVIORAL HEALTH Tier 1<br />
2701 E ENTERPRISE AVENUE<br />
07/01/2012<br />
APPLETON, WI 54913<br />
06/30/2014<br />
THEDACARE BEHAVIORAL HEALTH Tier 2<br />
600 N WESTHAVEN DRIVE<br />
07/01/2012<br />
OSHKOSH, WI 54901<br />
06/30/2014<br />
THEDACARE BEHAVIORAL HEALTH Tier 1<br />
3916 N INTERTECH COURT<br />
07/01/2012<br />
APPLETON, WI 54913<br />
06/30/2014<br />
THEDACARE BEHAVIORAL HEALTH Tier 2<br />
2500 E CAPITAL DRIVE<br />
07/01/2012<br />
APPLETON, WI 54911<br />
06/30/2014<br />
THEDACARE BEHAVIORAL HEALTH Tier 2<br />
902 RIVERSIDE DRIVE, #204<br />
07/01/2012<br />
WAUPACA, WI 54981<br />
06/30/2014<br />
THEDACARE BEHAVIORAL HEALTH Tier 1<br />
1405 MILL STREET<br />
07/01/2012<br />
NEW LONDON, WI 54961<br />
06/30/2014<br />
THEDACARE BEHAVIORAL HEALTH Tier 1<br />
W5282 AMY AVENUE<br />
07/01/2012<br />
APPLETON, WI 54915<br />
06/30/2014<br />
THEDACARE BEHAVIORAL HEALTH Tier 1<br />
640 DEERWOOD AVENUE<br />
07/01/2012<br />
NEENAH, WI 54956<br />
06/30/2014<br />
THEDACARE BEHAVIORAL HEALTH Tier 2<br />
100 COUNTY ROAD B<br />
07/01/2012<br />
SHAWANO, WI 54166<br />
06/30/2014<br />
THEDACARE BEHAVIORAL HEALTH Tier 2<br />
130 SECOND STREET<br />
07/01/2012<br />
NEENAH, WI 54956<br />
06/30/2014<br />
THEDACARE BEHAVIORAL HEALTH Tier 2<br />
1818 NORTH MEADE STREET<br />
07/01/2012<br />
APPLETON, WI 54911<br />
06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 300 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
2866<br />
TOTTY AND ASSOCIATES<br />
CYNTHIA TOTTY-HEFLEY<br />
7251 W NORTH AVENUE<br />
WAUWATOSA, WI 53213<br />
County: Milwaukee<br />
ctotty@sbcglobal.net<br />
Phone: (414) 258-6000<br />
Fax: (414) 258-3700<br />
Surveyor: Demetrius Anderson<br />
Services<br />
06/01/2009<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2765<br />
TRANSFORMATIONSERVICES<br />
INGRID HICKS<br />
835 N 23RD STREET, #212<br />
MILWAUKEE, WI 53233<br />
County: Milwaukee<br />
drhicks@transformationservices.<strong>in</strong>fo<br />
Phone: (414) 933-7083<br />
Fax: (414) 933-7883<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/18/2007<br />
01/01/2011<br />
12/31/2012<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2125<br />
TRANSITIONAL LIVING SERVICES, INC.<br />
COMMUNITY SUPPORT PROGRAM<br />
NICOLE MAJINSKI<br />
1040 S. 70TH STREET<br />
MILWAUKEE, WI 53214<br />
County: Milwaukee<br />
nicole.maj<strong>in</strong>ski@mcfi.net<br />
Phone: (414) 476-9675<br />
Fax: (414) 615-0627<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
06/01/2012 05/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1985<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011 06/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 301 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2112<br />
TRANSITIONAL LIVING SERVICES, INC. CSP<br />
JOHN CHIANELLI<br />
3710 DOUGLAS AVENUE<br />
RACINE, WI 53402<br />
County: Rac<strong>in</strong>e<br />
john.chianelli@mcfi.net<br />
Phone: (262) 639-8084<br />
Fax: (262) 639-8086<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1999<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1933<br />
TRANSITIONAL LIVING SERVICES, INC.<br />
LESLIE SPENCER<br />
1040 S. 70TH STREET<br />
MILWAUKEE, WI 53214<br />
County: Milwaukee<br />
LSpencer@mcfi.net<br />
Phone: (414) 476-9675<br />
Fax: (414) 615-0627<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1985<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2215<br />
TRANSITIONAL LIVING SERVICES, INC.<br />
JOHN CHIANELLI<br />
3710 DOUGLAS AVENUE<br />
RACINE, WI 53402<br />
County: Rac<strong>in</strong>e<br />
John.chianelli@mcfi.net<br />
Phone: (262) 639-8084<br />
Fax: (262) 639-8096<br />
Surveyor: Mark Isaacs<br />
Services<br />
07/01/2011 06/30/2013<br />
CRISIS RESOURCE CENTER Tier 2<br />
2057 S 14TH STREET<br />
10/05/2011<br />
MILWAUKEE, WI 53204<br />
05/31/2013<br />
MILWAUKEE CENTER FOR<br />
INDEPENDENCE<br />
Tier 1<br />
2020 W WELLS STREET<br />
06/01/2011<br />
MILWAUKEE, WI 53233<br />
05/31/2013<br />
TRANSITIONAL LIVING SERVICES INC Tier 1<br />
3710 DOUGLAS AVENUE<br />
06/01/2011<br />
RACINE, WI 53402<br />
05/31/2013<br />
WATER TOWER VIEW Tier 1<br />
3983 S PRAIRIE HILL LANE<br />
06/01/2011<br />
GREENFIELD, WI 53228<br />
05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2000<br />
04/01/2011<br />
03/31/2012<br />
CSAS-Residential Intoxication Monitor<strong>in</strong>g DHS 75.09<br />
NO BRANCH LOCATIONS<br />
06/01/2011 05/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2011 03/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 302 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2915<br />
TRANSITIONS BEHAVIORAL HEALTH, LLC<br />
JESSICA BECKETT<br />
317 DE WITT AVENUE<br />
PORTAGE, WI 53901<br />
County: Columbia<br />
transitions.office@frontier.com<br />
Phone: (608) 566-3813<br />
Fax: (608) 745-1757<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/2010<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2642<br />
TRANSITIONS CENTER, LLC<br />
RICHARD MARTIN<br />
22 N PELHAM STREET<br />
RHINELANDER, WI 54501<br />
County: Oneida<br />
transitionscenter@frontiernet.net<br />
Phone: (715) 365-6696<br />
Fax: (715) 365-6768<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2006<br />
02/01/2011<br />
01/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2564<br />
TRILLIUM CARE GROUP, LLC<br />
TERESA C. ORTIZ<br />
500 ELM GROVE ROAD, #100<br />
ELM GROVE, WI 53122<br />
County: Waukesha<br />
Tortiz@trilliumcare.com<br />
Phone: (262) 782-2090<br />
Fax: (262) 782-2092<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2005<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013<br />
TRILLIUM CARE GROUP LLC Tier 1<br />
4811 S 76TH ST, #309<br />
01/01/2012<br />
GREENFIELD, WI 53220<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 303 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1936<br />
TRINITEAM, INC.<br />
ROBERT PEITZMAN<br />
202 GRAHAM AVENUE<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
rob@tr<strong>in</strong>iteam.org<br />
Phone: (715) 858-9801<br />
Fax: (715) 836-8104<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/1989<br />
04/01/2011<br />
03/31/2013<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1938<br />
TURCOTT MEDICAL AND PSYCHIATRIC<br />
ASSOCIATES<br />
RICHARD TURCOTT<br />
2600 N. MAYFAIR ROAD, #785<br />
WAUWATOSA, WI 53226<br />
County: Milwaukee<br />
turcottmedical@yahoo.com<br />
Phone: (414) 258-5704<br />
Fax: (414) 258-8406<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1978<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1941<br />
UNIFIED COMMUNITY SERVICES COMMUNITY<br />
SUPPORT PROGRAM<br />
NEAL BLACKBURN, PHD<br />
200 W. ALONA LANE<br />
LANCASTER, WI 53813<br />
County: Grant<br />
cknapp@unifiedservices.org<br />
Phone: (608) 723-6357<br />
Fax: (608) 723-4417<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1994<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2010 09/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 304 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1942<br />
UNIFIED COMMUNITY SERVICES<br />
CHERYL KNAPP<br />
1122 PROFESSIONAL DRIVE<br />
DODGEVILLE, WI 53533<br />
County: Iowa<br />
cknapp@unifiedservices.org<br />
Phone: (608) 723-6357<br />
Fax: (608) 723-4417<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1975<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1943<br />
UNIFIED COMMUNITY SERVICES<br />
CHERYL KNAPP<br />
200 W. ALONA LANE<br />
LANCASTER, WI 53813<br />
County: Grant<br />
cknapp@unifiedservices.org<br />
Phone: (608) 723-6357<br />
Fax: (608) 723-4417<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 2 DHS 34.2<br />
1949<br />
UNITED COMMUNITY CENTER ART<br />
RENE FARIAS<br />
1011 SOUTH 8TH STREET<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
renef@unitedcc.org<br />
Phone: (414) 643-8530<br />
Fax: (414) 647-8602<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/03/1997<br />
10/01/2011<br />
09/30/2012<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2012<br />
10/01/2011 09/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 305 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2351<br />
UNITED COMMUNITY CENTER LATINAS UNIDAS<br />
RENE FARIAS<br />
1007 SOUTH 8TH STREET<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
renef@unitedcc.org<br />
Phone: (414) 643-8530<br />
Fax: (414) 647-8602<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/2001<br />
10/01/2010<br />
09/30/2012<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
1657<br />
UNITED COMMUNITY CENTER<br />
RENE FARIAS<br />
1100 S 6TH STREET, 3RD FLOOR<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
renef@unitedcc.org<br />
Phone: (414) 384-3100<br />
Fax: (414) 647-8602<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1980<br />
10/01/2010<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2881<br />
UNITED COMMUNITY CENTER<br />
RENE FARIAS<br />
604 W SCOTT STREET<br />
MILWAUKEE, WI 53204<br />
County: Milwaukee<br />
renef@unitedcc.org<br />
Phone: (414) 643-8530<br />
Fax: (414) 647-8602<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/13/2009<br />
08/01/2012<br />
07/31/2014<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
10/01/2010 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 306 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1940<br />
UNIVERSITY OF WI HOSPITALS & CLINICS<br />
CYNTHIA GREEN<br />
122 E. OLIN AVENUE, #275<br />
MADISON, WI 53713<br />
County: Dane<br />
CGreen@uwhealth.org<br />
Phone: (608) 262-1111<br />
Fax: (608) 263-9045<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1990<br />
02/01/2012<br />
01/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1953<br />
UNIVERSITY OF WISCONSIN HOSPITALS AND<br />
CLINICS AUTHORITY<br />
JACKIE SMITH-HELMANSTEIN<br />
600 HIGHLAND AVE, AOB-414<br />
MADISON, WI 53792<br />
County: Dane<br />
jSmith-Helmanste<strong>in</strong>@uwhealth.org<br />
Phone: (608) 821-4929<br />
Fax: (608) 662-3050<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1987<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
1956<br />
UPLANDS COUNSELING ASSOCIATES, INC.<br />
STEPHANIE KARWACKI<br />
9 ODANA COURT, #203<br />
MADISON, WI 53719<br />
County: Dane<br />
ucamadison@tds.net<br />
Phone: (608) 274-5181<br />
Fax: (608) 274-2848<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
02/01/2012 01/31/2014<br />
02/01/2012 01/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1994<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/2011 09/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 307 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1374<br />
UW HEALTH - GATEWAY RECOVERY<br />
MICHAEL WAUPOOSE<br />
25 KESSEL COURT, #200<br />
MADISON, WI 53711<br />
County: Dane<br />
michael.waupoose@uwmf.wisc.edu<br />
Phone: (608) 278-8200<br />
Fax: (608) 278-8204<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/01/1992<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1278<br />
UW HEALTH PARTNERS DIRECTIONS<br />
COUNSELING CENTER<br />
ERIC D BEAVER<br />
129 HOSPITAL DRIVE<br />
WATERTOWN, WI 53098<br />
County: Dodge<br />
ebeaver@uwhpwatertown.com<br />
Phone: (920) 262-4800<br />
Fax: (920) 262-4813<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/1981<br />
01/01/2012<br />
12/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1961<br />
VALENTIN CLINIC<br />
CYNTHIA VALENTIN<br />
1220 DEWEY AVENUE<br />
WAUWATOSA, WI 53213<br />
County: Milwaukee<br />
valent<strong>in</strong>cl<strong>in</strong>ic@sbcglobal.net<br />
Phone: (414) 454-6514<br />
Fax: (414) 454-6751<br />
Surveyor: Demetrius Anderson<br />
Services<br />
UW HEALTH PARTNERS LAKE MILLS<br />
CLINIC<br />
1025 MULBERRY STREET<br />
LAKE MILLS, WI 53551<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Tier 1<br />
01/01/2012<br />
12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/1992<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
01/01/2012 12/31/2013<br />
01/01/2012 12/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 308 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2960<br />
VERNON COUNTY DEPARTMENT OF HUMAN<br />
SERVICES/CENTER POINT COUNSELING<br />
SERVICES COOP<br />
PAM EITLAND<br />
318 FAIRLANE DRIVE<br />
VIROQUA, WI 54665<br />
County: Vernon<br />
No Email Address Provided<br />
Phone: (608) 637-5210<br />
Fax: (608) 637-5505<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/2011<br />
12/01/2011<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
1963<br />
VERNON MEMORIAL HOSPITAL<br />
SUE SULLIVAN<br />
507 S. MAIN STREET<br />
VIROQUA, WI 54665<br />
County: Vernon<br />
ssullivan@vmh.org<br />
Phone: (608) 637-2101<br />
Fax: (608) 637-2141<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/1978<br />
09/01/2012<br />
08/31/2014<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
2784<br />
VERONA COUNSELING ASSOCIATES<br />
JUDITH CRESSON<br />
111 E VERONA AVENUE<br />
VERONA, WI 53593<br />
County: Dane<br />
emski@chorus.net<br />
Phone: (608) 848-2574<br />
Fax: (608) 848-2574<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2008<br />
06/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
09/01/2012 08/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 309 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1965<br />
VILLA HOPE COMMUNITY SUPPORT PROGRAM OF<br />
BROWN COUNTY<br />
MOLLIE TOONEN<br />
1100 GUNS ROAD<br />
GREEN BAY, WI 54311<br />
County: Brown<br />
mtoonen@villahopecsp.com<br />
Phone: (920) 469-7030<br />
Fax: (920) 469-5599<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/06/1996<br />
03/01/2012<br />
02/28/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2398<br />
VIROQUA HEALING ARTS MENTAL HEALTH<br />
CENTER<br />
SUSAN KOPP TOWNSLEY<br />
224 EAST COURT STREET<br />
VIROQUA, WI 54665<br />
County: Vernon<br />
susan.townsley@viroquaheal<strong>in</strong>garts.com<br />
Phone: (608) 637-7600<br />
Fax: (608) 637-7328<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/22/2002<br />
08/01/2009<br />
07/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2663<br />
VISIONS COUNSELING, INC.<br />
GWENDOLYN MARTELL-WILLIAM<br />
N2355 SMITH ROAD<br />
MERRILL, WI 54452<br />
County: L<strong>in</strong>coln<br />
visionscounsel<strong>in</strong>g@yahoo.com<br />
Phone: (715) 551-1970<br />
Fax: (715) 539-3580<br />
Surveyor: Bradley Jahr<br />
Services<br />
03/01/2012 02/28/2014<br />
GOOD SHEPARD LUTHERAN CHURCH Tier 1<br />
504 S MAIN STREET<br />
06/07/2010<br />
VIROQUA, WI 54665<br />
07/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/22/2006<br />
03/01/2010<br />
02/28/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
08/01/2009 07/31/2011<br />
VISIONS COUNSELING, INC. Tier 1<br />
2801 N 7TH STREET, #400G<br />
03/01/2010<br />
WAUSAU, WI 54403<br />
02/28/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/01/2010 02/28/2011
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 310 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2694<br />
WALWORTH COUNTY DEPT OF HEALTH & HUMAN<br />
SERVICES COMMUNITY SUPPORT PROGRAM<br />
LISA KADLEC<br />
W4051 COUNTY ROAD NN<br />
ELKHORN, WI 53121<br />
County: Walworth<br />
lkadlec@co.walworth.wi.us<br />
Phone: (262) 741-3200<br />
Fax: (262) 741-3217<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/08/2006<br />
12/01/2011<br />
11/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2889<br />
WALWORTH COUNTY DHHS COMPREHENSIVE<br />
COMMUNITY SERVICES<br />
LISA KADLEC<br />
W4051 COUNTY ROAD NN<br />
ELKHORN, WI 53121<br />
County: Walworth<br />
lkadlec@co.walworth.wi.us<br />
Phone: (262) 741-3200<br />
Fax: (262) 741-3217<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/20/2010<br />
02/01/2011<br />
01/31/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
1967<br />
WALWORTH COUNTY HEALTH AND HUMAN<br />
SERVICES<br />
ELIZABETH ALDRED<br />
W4051 COUNTY TRUNK NN<br />
ELKHORN, WI 53121<br />
County: Walworth<br />
walcohhs@co.walworth.wi.us<br />
Phone: (262) 741-3200<br />
Fax: (262) 741-3217<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2011 11/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
09/01/2012<br />
08/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
NO BRANCH LOCATIONS<br />
02/01/2011 01/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014<br />
09/01/2012 08/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 311 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2926<br />
WASHBURN COUNTY COMMUNITY SUPPORT<br />
PROGRAM<br />
JIM LEDUC<br />
702 FRONT STREET<br />
SPOONER, WI 54801<br />
County: Washburn<br />
JLeduc@co.washburn.wi.us<br />
Phone: (715) 635-3539<br />
Fax: (715) 635-3539<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/2010<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2635<br />
WASHBURN COUNTY HEALTH AND HUMAN<br />
SERVICES DEPARTMENT<br />
JOHN MCMAHON<br />
110 - 4TH AVENUE<br />
SHELL LAKE, WI 54871<br />
County: Washburn<br />
No Email Address Provided<br />
Phone: (715) 468-4745<br />
Fax: (715) 468-4770<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2005<br />
12/01/2005<br />
11/30/2006<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2303<br />
WASHINGTON COUNTY MENTAL HEALTH CENTER<br />
COMMUNITY SUPPORT PROGRAM<br />
STEPHANIE GUDMUNSEN<br />
333 E. WASHINGTON ST SUITE 2100<br />
WEST BEND, WI 53095<br />
County: Wash<strong>in</strong>gton<br />
kay.theucks@co.wash<strong>in</strong>gton.wi.us<br />
Phone: (262) 335-4600<br />
Fax: (262) 335-6827<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
05/01/2012<br />
04/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
12/01/2005 11/30/2006<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2012 04/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 312 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2580<br />
WASHINGTON COUNTY MENTAL HEALTH CENTER<br />
COMPREHENSIVE COMMUNITY SERVICES<br />
KAY THUECKS<br />
333 E WASHINGTON STREET, #2100<br />
WEST BEND, WI 53090<br />
County: Wash<strong>in</strong>gton<br />
kay.thuecks@co.wash<strong>in</strong>gton.wi.us<br />
Phone: (262) 335-4600<br />
Fax: (262) 335-6827<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/2005<br />
03/01/2012<br />
02/28/2014<br />
Comprehensive Community Services (CCS) DHS 36<br />
1968<br />
WASHINGTON COUNTY MENTAL HEALTH CENTER<br />
JIM STRACHOTA<br />
333 E. WASHINGTON STREET #2000<br />
WEST BEND, WI 53095<br />
County: Wash<strong>in</strong>gton<br />
jim.strachota@co.wash<strong>in</strong>gton.wi.us<br />
Phone: (262) 335-4545<br />
Fax: (262) 335-6827<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2593<br />
WAUKESHA COUNTY HEALTH AND HUMAN<br />
SERVICES COMPREHENSIVE COMMUNITY<br />
SERVICES<br />
DANIELLE BIRDEAU<br />
1501 AIRPORT ROAD<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
dbirdeau@waukeshacounty.gov<br />
Phone: (262) 548-7950<br />
Fax: (262) 896-8180<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/15/2005<br />
07/01/2012<br />
06/30/2014<br />
Comprehensive Community Services (CCS) DHS 36<br />
NO BRANCH LOCATIONS<br />
05/01/2011 04/30/2013<br />
05/01/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 313 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1972<br />
WAUKESHA COUNTY HEALTH AND HUMAN<br />
SERVICES-COMMUNITY SUPPORT PROGRAM<br />
M SUSAN WALKER<br />
1501 AIRPORT ROAD<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
SWalker@waukeshacounty.gov<br />
Phone: (262) 548-7950<br />
Fax: (262) 896-8046<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1990<br />
10/01/2011<br />
09/30/2013<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1970<br />
WAUKESHA COUNTY MENTAL HEALTH CENTER<br />
GORDON OWLEY, PHD<br />
500 RIVERVIEW AVENUE<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
gowley@waukeshacounty.gov<br />
Phone: (262) 548-7666<br />
Fax: (262) 548-7656<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1984<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
1971<br />
WAUKESHA COUNTY MENTAL HEALTH CENTER<br />
MICHELE CUSATIS<br />
1501 AIRPORT ROAD<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
mcusatis@waukeshacounty.gov<br />
Phone: (262) 548-7950<br />
Fax: (262) 896-8046<br />
Surveyor: Mark Isaacs<br />
Services<br />
WAUKESHA COUNTY MENTAL HEALTH<br />
CENTER<br />
1501 AIRPORT RD<br />
WAUKESHA, WI 53188<br />
10/01/2011 09/30/2013<br />
Tier 1<br />
04/01/2012<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1987<br />
04/01/2012<br />
03/31/2014<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
NO BRANCH LOCATIONS<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 314 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2185<br />
WAUKESHA HEALTH SYSTEM BEHAV MED CTR<br />
DBA DN GREENWALD CTR-PHC-MUKWONAGO<br />
BARBARA JONES<br />
240 W MAPLE STREET<br />
MUKWONAGO, WI 53149<br />
County: Waukesha<br />
barbara.jones@phci.org<br />
Phone: (262) 928-2396<br />
Fax: (262) 928-7812<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/1999<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2504<br />
WAUKESHA HEALTH SYSTEM BEHAVIORAL<br />
MEDICINE CENTER OUTPATIENT-OCONOMOWOC<br />
BARBARA JONES<br />
1185 CORPORATE CENTER DRIVE<br />
OCONOMOWOC, WI 53066<br />
County: Waukesha<br />
barbara.jones@phci.org<br />
Phone: (262) 928-2396<br />
Fax: (262) 978-7812<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2004<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2184<br />
WAUKESHA HEALTH SYSTEM DBA BEHAVIORAL<br />
MEDICINE CENTER @ PHC-MUSKEGO<br />
BARBARA JONES<br />
S69 W15636 JANESVILLE ROAD<br />
MUSKEGO, WI 53150<br />
County: Waukesha<br />
barbara.jones@phci.org<br />
Phone: (262) 928-2396<br />
Fax: (262) 928-7812<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1999<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 315 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2342<br />
WAUKESHA HEALTH SYSTEM DBA BEHAVIORAL<br />
MEDICINE CENTER @ PHC-NEW BERLIN<br />
BARBARA JONES<br />
13900 W. NATIONAL AVENUE<br />
NEW BERLIN, WI 53151<br />
County: Waukesha<br />
barbara.jones@phci.org<br />
Phone: (262) 928-2396<br />
Fax: (262) 928-7812<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/2001<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1974<br />
WAUKESHA HEALTH SYSTEM DBA BEHAVIORAL<br />
MEDICINE CENTER @PHC-WAUKESHA<br />
BARBARA JONES<br />
721 AMERICAN AVENUE, #501<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
barbara.jones@phci.org<br />
Phone: (262) 928-2396<br />
Fax: (262) 928-7812<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1986<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2182<br />
WAUKESHA HLTH SYS DBA BEHAVIORAL<br />
MEDICINE CENTER @ PHC-BROOKFIELD<br />
BARBARA JONES<br />
2085 N. CALHOUN ROAD<br />
BROOKFIELD, WI 53005<br />
County: Waukesha<br />
barbara.jones@phci.org<br />
Phone: (262) 928-2396<br />
Fax: (262) 928-7812<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1999<br />
12/01/2010<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/2010 11/30/2012<br />
12/01/2010 11/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 316 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1976<br />
WAUKESHA MEMORIAL HOSPITAL<br />
BARBARA JONES, RN<br />
725 AMERICAN AVENUE<br />
WAUKESHA, WI 53188<br />
County: Waukesha<br />
Barbara.Jones@phci.org<br />
Phone: (262) 928-2396<br />
Fax: (262) 928-7812<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
06/01/1986<br />
01/01/2011<br />
12/31/2012<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Medically Managed Inpatient Treatment DHS 75.10<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2123<br />
WAUPACA COUNTY DEPARTMENT OF HEALTH &<br />
HUMAN SERVICES CSP<br />
CHUCK PRICE<br />
811 HARDING STREET<br />
WAUPACA, WI 54981<br />
County: Waupaca<br />
wcdhhs@co.waupaca.wi.us<br />
Phone: (715) 258-6324<br />
Fax: (715) 258-6409<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1981<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1977<br />
WAUPACA COUNTY DEPARTMENT OF HEALTH<br />
AND HUMAN SERVICES<br />
CHUCK PRICE<br />
811 HARDING STREET<br />
WAUPACA, WI 54981<br />
County: Waupaca<br />
wcdhhs@co.waupaca.wi.us<br />
Phone: (715) 258-6304<br />
Fax: (715) 258-6409<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
01/01/2011 12/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1981<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
WAUPACA CO DEPT OF HEALTH &<br />
HUMAN SERV<br />
1405 MILL ST<br />
NEW LONDON, WI 54961<br />
07/01/2012 06/30/2014<br />
Tier 1<br />
07/01/2012<br />
06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 317 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1979<br />
WAUSHARA COUNTY DEPARTMENT OF HUMAN<br />
SERVICES CSP<br />
DAWN ANDERSON-MUELLER<br />
230 W. PARK STREET<br />
WAUTOMA, WI 54982<br />
County: Waushara<br />
dawna.parkstreet@co.waushara.wi.us<br />
Phone: (920) 787-6550<br />
Fax: (920) 787-0421<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/01/1997<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1980<br />
WAUSHARA COUNTY DEPARTMENT OF HUMAN<br />
SERVICES<br />
SUE SHEMANSKI<br />
230 W. PARK STREET<br />
WAUTOMA, WI 54982<br />
County: Waushara<br />
sues.parkstreet@co.waushara.wi.us<br />
Phone: (920) 787-6550<br />
Fax: (920) 787-0421<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
WAUSHARA COUNTY DEPT OF HUMAN<br />
SERVICES<br />
N 7046 COUNTY ROAD CH<br />
WESTFIELD, WI 53964<br />
WAUSHARA COUNTY DEPT OF HUMAN<br />
SERVICES<br />
409 S WEST STREET<br />
PLAINFIELD, WI 54966<br />
WAUSHARA COUNTY DEPT OF HUMAN<br />
SERVICES<br />
222 MEMORIAL DRIVE<br />
BERLIN, WI 54923<br />
WAUSHARA COUNTY DEPT OF HUMAN<br />
SERVICES<br />
514 S CAMBRIDGE STREET<br />
WAUTOMA, WI 54982<br />
11/01/2010 10/31/2012<br />
Tier 1<br />
11/01/2010<br />
10/31/2012<br />
Tier 1<br />
11/01/2010<br />
10/31/2012<br />
Tier 1<br />
11/01/2010<br />
10/31/2012<br />
Tier 1<br />
11/01/2010<br />
10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 318 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2618<br />
WAUSHARA COUNTY HUMAN SERVICES<br />
COMPREHENSIVE COMMUNITY SERVICES<br />
DAWN ANDERSON-MUELLER<br />
230 W PARK STREET<br />
WAUTOMA, WI 54982<br />
County: Waushara<br />
dawna.parkstreet@co.waushara.wi.us<br />
Phone: (920) 787-6550<br />
Fax: (920) 787-0421<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/19/2005<br />
11/01/2010<br />
10/31/2012<br />
Comprehensive Community Services (CCS) DHS 36<br />
2813<br />
WAY OF THE WILLOW, LLC<br />
DAWN ZAK<br />
216 N GREEN BAY ROAD, #208<br />
THIENSVILLE, WI 53092<br />
County: Ozaukee<br />
dzakwillowway@sbcglobal.net<br />
Phone: (414) 322-6184<br />
Fax: No Number Provided<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2008<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1982<br />
WELLNESS COUNSELING CENTER<br />
BEDFORD HINES<br />
103 W. COLLEGE AVENUE, #815<br />
APPLETON, WI 54911<br />
County: Outagamie<br />
No Email Address Provided<br />
Phone: (920) 733-1992<br />
Fax: (920) 733-1866<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/01/1981<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
11/01/2011 10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 319 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2852<br />
WELLSPRING COUNSELING CENTER, INC.<br />
SHERI MCALLISTER, MA, LPC<br />
310 OLD GREEN BAY ROAD<br />
KENOSHA, WI 53144<br />
County: Kenosha<br />
sheri@wellspr<strong>in</strong>g.com<br />
Phone: (262) 883-9400<br />
Fax: (262) 898-1635<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/30/2009<br />
05/01/2010<br />
04/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1983<br />
WELLSPRING PSYCHOTHERAPY AND<br />
COUNSELING CENTER<br />
BRYCE MITCHELL<br />
5610 MEDICAL CIRCLE, SUITE 25<br />
MADISON, WI 53719<br />
County: Dane<br />
wellspr<strong>in</strong>gpsych@charter.net<br />
Phone: (608) 274-5888<br />
Fax: (608) 274-5764<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1996<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1985<br />
WEST ALLIS PSYCHIATRIC ASSOCIATES<br />
MARIE SARNOWSKI<br />
2424 S. 90TH STREET, #402<br />
WEST ALLIS, WI 53227<br />
County: Milwaukee<br />
westallispsych@biswi.rr.com<br />
Phone: (414) 328-8690<br />
Fax: (414) 328-8691<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
05/01/2010 04/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
12/27/1993<br />
01/01/2011<br />
12/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2011 12/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 320 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2543<br />
WEST CENTRAL WISCONSIN BEHAVIORAL<br />
HEALTH CLINIC<br />
CURTIS A JOHNSON<br />
206 SOUTH ROOSEVELT RD, #112<br />
BLACK RIVER FALLS, WI 54615<br />
County: Jackson<br />
No Email Address Provided<br />
Phone: (715) 538-4312<br />
Fax: (715) 985-3029<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
09/03/2004<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
2318<br />
WEST GROVE CLINIC<br />
TRACI MARETT<br />
12425 KNOLL ROAD SUITE 110<br />
ELM GROVE, WI 53122<br />
County: Waukesha<br />
westgrovecl<strong>in</strong>ic@yahoo.com<br />
Phone: (262) 780-9788<br />
Fax: (262) 432-0045<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
WEST CENTRAL WISCONSIN<br />
BEHAVIORAL HEALTH CLINIC<br />
23062 WHITEHALL ROAD<br />
INDEPENDENCE, WI 54747<br />
Tier 1<br />
09/01/2011<br />
08/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/22/2001<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2533<br />
WETZEL-RASMUSSEN COUNSELING SERVICES<br />
NATALIE WETZEL-RASMUSSEN<br />
N11230 ANTIGO STREET<br />
ELCHO, WI 54428<br />
County: Langlade<br />
drnat@frontiernet.net<br />
Phone: (715) 275-3934<br />
Fax: (715) 275-4510<br />
Surveyor: Bradley Jahr<br />
Services<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
WEST GROVE CLINIC LLC Tier 2<br />
11121 W NORTH AVENUE, #220<br />
07/01/2012<br />
WAUWATOSA, WI 53226<br />
06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2004<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
WETZEL-RASMUSSEN COUNSELING<br />
SERVICES<br />
4939 ST HWY 70 WEST<br />
EAGLE RIVER, WI 54521<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Tier 1<br />
07/01/2011<br />
12/01/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011 06/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 321 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2547<br />
WHEATON FRANCISCAN BEHAVIORAL HEALTH -<br />
ST. FRANCIS HOSPITAL<br />
CAROL HESS<br />
3237 S. 16TH STREET #200<br />
MILWAUKEE, WI 53215<br />
County: Milwaukee<br />
Carol.Hess@wfhc.org<br />
Phone: (414) 389-3111<br />
Fax: (414) 389-3110<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/27/2004<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
2654<br />
WHEATON FRANCISCAN BEHAVIORAL HEALTH -<br />
ST. JOSEPH HOSPITAL II<br />
CAROL HESS<br />
13950 W CAPITOL DRIVE, 2ND FLOOR<br />
BROOKFIELD, WI 53005<br />
County: Waukesha<br />
Carol.Hess@wfhc.org<br />
Phone: (414) 874-4574<br />
Fax: (414) 874-4565<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
WHEATON FRAN BEHAV HEALTH - ST.<br />
FRANCIS<br />
5650 N GREEN BAY AVENUE, #200<br />
BROWN DEER, WI 53209<br />
Tier 1<br />
11/01/2011<br />
10/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/22/2005<br />
09/01/2011<br />
08/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2548<br />
WHEATON FRANCISCAN BEHAVIORAL HEALTH -<br />
ST. JOSEPH REGIONAL MEDICAL CENTER<br />
CAROL HESS<br />
5000 W. CHAMBERS STREET #P210<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
carol.hess@wfhc.org<br />
Phone: (414) 874-1171<br />
Fax: (414) 874-1177<br />
Surveyor: Demetrius Anderson<br />
Services<br />
WHEATON FRANCISCAN BEHAVIORAL<br />
HEALTH<br />
1292 CAPITOL DRIVE<br />
PEWAUKEE, WI 53072<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013<br />
Tier 1<br />
09/01/2011<br />
08/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/27/2004<br />
11/01/2011<br />
10/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
09/01/2011 08/31/2013<br />
09/01/2011 08/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2011 10/31/2013<br />
11/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 322 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2310<br />
WHEATON FRANCISCAN CENTER FOR ADDICTION<br />
RECOVERY<br />
WILLIAM STONER<br />
9301 WASHINGTON AVENUE<br />
RACINE, WI 53406<br />
County: Rac<strong>in</strong>e<br />
William.stoner@wfhc.org<br />
Phone: (262) 687-8626<br />
Fax: (262) 687-8611<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/11/2001<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1027<br />
WHEATON FRANCISCAN HEALTHCARE - ALL<br />
SAINTS MENTAL HEALTH & ADDICTION CARE<br />
JULIE HUELLER, RN<br />
1320 WISCONSIN AVENUE<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
julie.hueller@wfhc.org<br />
Phone: (262) 687-2136<br />
Fax: (262) 687-2802<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1990<br />
07/01/2010<br />
06/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Medically Managed Inpatient Detox DHS 75.06<br />
CSAS-Medically Managed Inpatient Treatment DHS 75.10<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment DHS 61.75<br />
<strong>Mental</strong> <strong>Health</strong>-Day Treatment for Children 3 DHS 40.11(2)(c)<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
WHEATON FRANCISCAN<br />
HEALTHCARE-ALL SAINTS<br />
2408 FOUR MILE ROAD<br />
RACINE, WI 53402<br />
WHEATON FRANCISCAN<br />
HEALTHCARE-ALL SAINTS<br />
3805B SPRING STREET, #240<br />
RACINE, WI 53405<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
08/01/2012 07/31/2014<br />
Tier 1<br />
08/01/2011<br />
06/30/2012<br />
Tier 2<br />
07/01/2010<br />
06/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2010 06/30/2012<br />
07/01/2010 06/30/2012<br />
07/01/2010 06/30/2012<br />
07/01/2010 06/30/2012<br />
07/01/2010 06/30/2012<br />
07/01/2010 06/30/2012<br />
07/01/2010 06/30/2012<br />
07/01/2010 06/30/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 323 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2732<br />
WHEATON FRANCISCAN HEALTHCARE ALL<br />
SAINTS<br />
JULIE HEULLER<br />
3805B SPRING STREET #240<br />
RACINE, WI 53405<br />
County: Rac<strong>in</strong>e<br />
No Email Address Provided<br />
Phone: (262) 687-8118<br />
Fax: (262) 687-8109<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
04/20/2007<br />
05/01/2008<br />
04/30/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
1028<br />
WHEATON FRANCISCAN HEALTHCARE<br />
COUNSELING CENTER BURLINGTON<br />
WILLIAM M.STONER<br />
152 E. STATE STREET<br />
BURLINGTON, WI 53105<br />
County: Rac<strong>in</strong>e<br />
william.stoner@WFHC.org<br />
Phone: (262) 763-8183<br />
Fax: (262) 763-9394<br />
Surveyor: Mark Isaacs<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/1990<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2300<br />
WHEATON FRANCISCAN HEALTHCARE<br />
COUNSELING CENTER KENOSHA<br />
WILLIAM M. STONER<br />
10117 - 74TH STREET, #100<br />
KENOSHA, WI 53142<br />
County: Kenosha<br />
william.stoner@wfhc.org<br />
Phone: (262) 687-7650<br />
Fax: (262) 687-7656<br />
Surveyor: Mark Isaacs<br />
Services<br />
WHEATON FRAN MEDICAL<br />
GROUP-UNION GROVE<br />
1120 MAIN ST<br />
UNION GROVE, WI 53182<br />
05/01/2008 04/30/2010<br />
Tier 1<br />
04/01/2012<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/05/2001<br />
04/01/2012<br />
03/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
WHEATON FRAN HEALTHCARE SOUTH<br />
SIDE<br />
6232 BANKERS RD<br />
RACINE, WI 53403<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014<br />
Tier 1<br />
04/01/2012<br />
03/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2012 03/31/2014<br />
04/01/2012 03/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 324 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1986<br />
WHITE'S RESIDENTIAL TREATMENT AND<br />
CLINICAL SERVICES, INC.<br />
LANELL WHITE<br />
2811 W. NORTH AVENUE<br />
MILWAUKEE, WI 53208<br />
County: Milwaukee<br />
whitesrtf@sbcglobal.com<br />
Phone: (414) 372-3713<br />
Fax: (414) 372-3732<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/07/1998<br />
10/01/2010<br />
09/30/2012<br />
CSAS-Transitional Residential DHS 75.14<br />
2665<br />
WHITE'S RESIDENTIAL TREATMENT AND<br />
CLINICAL SERVICES, INC.<br />
LANELL WHITE<br />
4020 W BURLEIGH STREET<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
whitesrtf@sbcglobal.net<br />
Phone: (414) 445-7288<br />
Fax: (414) 445-7708<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/11/2006<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
1989<br />
WHOLISTIC HEALTH COUNSELING SERVICES<br />
MARIANNE HELM<br />
5934 S. BUSINESS DRIVE, HWY OK<br />
SHEBOYGAN, WI 53081<br />
County: Sheboygan<br />
wholistic@choiceonemail.com<br />
Phone: (920) 459-9277<br />
Fax: (920) 459-7920<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
10/01/2010 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/18/1990<br />
05/01/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
04/01/2012 10/31/2012<br />
07/01/2011 03/31/2012<br />
04/01/2011 03/31/2013<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/2011 04/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 325 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1199<br />
WI LUTHERAN CHILD & FAMILY SERVICE, INC.<br />
D/B/A CHRISTIAN FAMILY COUNSELING<br />
MYLES TONNACLIFF<br />
W175 N11120 STONEWOOD DR<br />
GERMANTOWN, WI 53022<br />
County: Wash<strong>in</strong>gton<br />
mtonnacliff@wlcfs.org<br />
Phone: (414) 368-6080<br />
Fax: (414) 368-6073<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
12/01/1987<br />
03/31/2012<br />
11/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1997<br />
WI LUTHERAN CHILD & FAMILY SERVICE, INC.<br />
D/B/A CHRISTIAN FAMILY COUNSELING<br />
DR MYLES TONNACLIFF<br />
1049 N LYNNDALE DRIVE, #1B<br />
APPLETON, WI 54914<br />
County: Outagamie<br />
mtonnacliff@wlcfs.org<br />
Phone: (262) 345-5535<br />
Fax: (262) 345-5531<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
THE BEACON BUILDING Tier 1<br />
17100 W NORTH AVENUE, #202<br />
03/31/2012<br />
BROOKFIELD, WI 53005<br />
11/30/2012<br />
WI LUTHERAN CHILD & FAMILY SERVICE<br />
INC<br />
Tier 1<br />
2345 N 25TH STREET<br />
03/31/2012<br />
MILWAUKEE, WI 53206<br />
11/30/2012<br />
WI LUTHERAN CHILD & FAMILY SERVICE<br />
INC<br />
Tier 1<br />
3601 N PORT WASHINGTON ROAD<br />
03/31/2012<br />
MILWAUKEE, WI 53212<br />
11/30/2012<br />
WLCFS-CHRISTIAN FAMILY<br />
COUNSELING<br />
Tier 2<br />
120 N MAIN STREET<br />
03/31/2012<br />
WEST BEND, WI 53095<br />
11/30/2012<br />
WLCFS-CHRISTIAN FAMILY<br />
COUNSELING<br />
Tier 1<br />
1214 S 8TH STREET<br />
03/31/2012<br />
MILWAUKEE, WI 53204<br />
11/30/2012<br />
WLCFS-CHRISTIAN FAMILY<br />
COUNSELING<br />
Tier 1<br />
9555 S HOWELL AVENUE, #750<br />
03/31/2012<br />
OAK CREEK, WI 53154<br />
11/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1990<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
WLCFS INC - CHRISTIAN FAMILY<br />
COUNSELING<br />
757 S MAIN STREET<br />
FOND DU LAC, WI 54935<br />
03/31/2012 11/30/2012<br />
Tier 1<br />
09/01/2010<br />
08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/2010 08/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 326 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2004<br />
WILLOWGLEN THERAPY ASSOCIATES<br />
NATHAN ZEIGER<br />
5555 NORTH 51ST BLVD<br />
MILWAUKEE, WI 53218<br />
County: Milwaukee<br />
Nzeiger@phoenixcaresystems.com<br />
Phone: (414) 527-6970<br />
Fax: (414) 527-6971<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/01/1992<br />
08/01/2012<br />
07/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2266<br />
WINNEBAGO COUNTY DEPARTMENT OF HUMAN<br />
SERVICES CSP<br />
MICHAEL DAEHN PHD<br />
220 WASHINGTON AVENUE<br />
OSHKOSH, WI 54903<br />
County: W<strong>in</strong>nebago<br />
mdaehn@co.w<strong>in</strong>nebago.wi.us<br />
Phone: (920) 236-4700<br />
Fax: (920) 303-4792<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
WILLOWGLEN THERAPY ASSOC @<br />
CORNERSTONE<br />
3903 W LISBON AVENUE<br />
MILWAUKEE, WI 53208<br />
Tier 2<br />
08/01/2012<br />
07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
2278<br />
WINNEBAGO COUNTY DEPARTMENT OF HUMAN<br />
SERVICES CSP<br />
MICHAEL DAEHN PHD<br />
211 N. COMMERCIAL STREET<br />
NEENAH, WI 54956<br />
County: W<strong>in</strong>nebago<br />
mdaehn@co.w<strong>in</strong>nebago.wi.us<br />
Phone: (920) 729-2777<br />
Fax: (920) 720-9682<br />
Surveyor: Frank Bellaire<br />
Services<br />
NO BRANCH LOCATIONS<br />
08/01/2012 07/31/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2000<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/01/2010 10/31/2012
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 327 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2006<br />
WINNEBAGO COUNTY DEPARTMENT OF HUMAN<br />
SERVICES<br />
MICHAEL DEAHN PHD<br />
211 N. COMMERCIAL STREET<br />
NEENAH, WI 54956<br />
County: W<strong>in</strong>nebago<br />
mdaehn@co.w<strong>in</strong>nebago.wi.us<br />
Phone: (920) 729-2777<br />
Fax: (920) 729-2790<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
07/01/1988<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2007<br />
WINNEBAGO COUNTY DEPARTMENT OF HUMAN<br />
SERVICES<br />
MICHAEL DAEHN PHD<br />
220 WASHINGTON AVENUE<br />
OSHKOSH, WI 54903<br />
County: W<strong>in</strong>nebago<br />
mdaehn@co.w<strong>in</strong>nebago.wi.us<br />
Phone: (920) 236-4700<br />
Fax: (920) 303-4792<br />
Surveyor: Frank Bellaire<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
10/01/1975<br />
11/01/2010<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Prevention DHS 75.04<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
2579<br />
WINNEBAGO COUNTY DHS COMPREHENSIVE<br />
COMMUNITY SERVICES<br />
MICHAEL DAEHN PHD<br />
220 WASHINGTON AVENUE<br />
OSHKOSH, WI 54903<br />
County: W<strong>in</strong>nebago<br />
Mdaehn@co.w<strong>in</strong>nebago.wi.us<br />
Phone: (920) 236-4700<br />
Fax: (920) 303-4792<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
03/09/2005<br />
04/01/2011<br />
03/31/2013<br />
Comprehensive Community Services (CCS) DHS 36<br />
NO BRANCH LOCATIONS<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
11/01/2010 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2011 03/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 328 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2008<br />
WINNEBAGO MENTAL HEALTH INSTITUTE<br />
THOMAS SPEECH<br />
TREFFERT DRIVE & BUTLER AVENUE<br />
WINNEBAGO, WI 54985<br />
County: W<strong>in</strong>nebago<br />
No Email Address Provided<br />
Phone: (920) 235-4910<br />
Fax: (920) 237-2043<br />
Surveyor: Frank Bellaire<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
10/01/1975<br />
11/01/2009<br />
10/31/2011<br />
CSAS-Medically Managed Inpatient Treatment DHS 75.10<br />
CSAS-Medically Monitored Treatment DHS 75.11<br />
CSAS-Outpatient Treatment DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Adolescent Inpatient DHS 61.79<br />
<strong>Mental</strong> <strong>Health</strong>-Inpatient DHS 61.71<br />
1995<br />
WISCONSIN COMMUNITY SERVICES OUTPATIENT<br />
MENTAL HEALTH PROGRAM<br />
COLLEEN DUBLINSKI<br />
3734 W. WISCONSIN AVENUE<br />
MILWAUKEE, WI 53208<br />
County: Milwaukee<br />
colleen@wiscs.org<br />
Phone: (414) 343-3515<br />
Fax: (414) 344-2191<br />
Surveyor: Demetrius Anderson<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1977<br />
07/01/2011<br />
06/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
1994<br />
WISCONSIN COMMUNITY SERVICES THE JOSHUA<br />
GLOVER CENTER<br />
DOUG HINTON<br />
2105 N. BOOTH STREET<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
dh<strong>in</strong>ton@wiscs.org<br />
Phone: (414) 263-4481<br />
Fax: (414) 226-0351<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
11/01/2009 10/31/2011<br />
11/01/2009 10/31/2011<br />
08/19/2010 10/31/2011<br />
11/01/2009 10/31/2011<br />
11/01/2009 10/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1990<br />
07/01/2011<br />
06/30/2013<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
07/01/2011 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2011 06/30/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 329 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1930<br />
WISCONSIN COMMUNITY SERVICES THURGOOD<br />
MARSHALL HOUSE<br />
DOUG HINTON<br />
1914 N. 6TH STREET<br />
MILWAUKEE, WI 53212<br />
County: Milwaukee<br />
dh<strong>in</strong>ton@wiscs.org<br />
Phone: (414) 264-7447<br />
Fax: (414) 226-0351<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/01/1992<br />
07/01/2012<br />
06/30/2013<br />
CSAS-Transitional Residential DHS 75.14<br />
1955<br />
WISCONSIN COMMUNITY SERVICES UNLIMITED<br />
POTENTIALS<br />
DOUG HINTON<br />
230 W. WELLS STREET, #500<br />
MILWAUKEE, WI 53203<br />
County: Milwaukee<br />
dh<strong>in</strong>ton@wiscs.org<br />
Phone: (414) 290-0446<br />
Fax: (414) 226-0351<br />
Surveyor: William Goehr<strong>in</strong>g<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/1986<br />
10/01/2011<br />
09/30/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2005<br />
WISCONSIN COMMUNITY SERVICES WINGS<br />
PROGRAM<br />
HELEN JOHNSON-LEMON<br />
2303 W. GALENA STREET<br />
MILWAUKEE, WI 53205<br />
County: Milwaukee<br />
Hjohnson@wiscs.org<br />
Phone: (414) 342-4621<br />
Fax: (414) 342-0489<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1994<br />
07/01/2012<br />
06/30/2014<br />
CSAS-Transitional Residential DHS 75.14<br />
NO BRANCH LOCATIONS<br />
10/01/2011 09/30/2012<br />
10/01/2011 09/30/2012<br />
10/01/2011 09/30/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2012 06/30/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 330 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
1993<br />
WISCONSIN COMMUNITY SERVICES-COMMUNITY<br />
SUPPORT PROGRAM<br />
JANET WIMMER<br />
3734 W. WISCONSIN AVENUE<br />
MILWAUKEE, WI 53208<br />
County: Milwaukee<br />
jwimmer@wiscs.org<br />
Phone: (414) 344-6111<br />
Fax: (414) 334-2191<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
11/01/1995<br />
06/01/2011<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong>-Community Support Program DHS 63<br />
1996<br />
WISCONSIN EARLY AUTISM PROJECT, INC.<br />
KIM SCHUTT-CHARDON<br />
1210 FOURIER DRIVE SUITE 100<br />
MADISON, WI 53717<br />
County: Dane<br />
kim.schutt-chardon@wiautism.com<br />
Phone: (608) 662-9327<br />
Fax: (608) 662-9041<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/01/1997<br />
06/27/2011<br />
04/30/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2440<br />
WISCONSIN EARLY AUTISM PROJECT, INC.<br />
KIM SCHUTT-CHARDON<br />
2125 HEIGHTS DRIVE SUITE 2F<br />
EAU CLAIRE, WI 54701<br />
County: Eau Claire<br />
kim.schutt-chardon@wiautism.com<br />
Phone: (715) 832-2233<br />
Fax: (715) 833-1666<br />
Surveyor: Polly Wong<br />
Services<br />
NO BRANCH LOCATIONS<br />
06/01/2011 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/12/2003<br />
06/01/2011<br />
05/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
06/27/2011 04/30/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2011 05/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 331 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2441<br />
WISCONSIN EARLY AUTISM PROJECT, INC.<br />
GLEN O SALLOWS<br />
1113 RIDERS CLUB ROAD<br />
ONALASKA, WI 54650<br />
County: La Crosse<br />
kim.schutt-chardon@wiautism.com<br />
Phone: (608) 781-6500<br />
Fax: (608) 783-7642<br />
Surveyor: Polly Wong<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
05/13/2003<br />
06/01/2009<br />
05/31/2011<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2460<br />
WISCONSIN EARLY AUTISM PROJECT, INC.<br />
KIM SCHUTT-CHARDON<br />
1141 W. MAIN AVE #201<br />
DE PERE, WI 54115<br />
County: Brown<br />
kim.schutt-chardon@wiautism.com<br />
Phone: (608) 662-9041<br />
Fax: (608) 662-9041<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
04/01/2003<br />
04/01/2011<br />
03/31/2013<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2461<br />
WISCONSIN EARLY AUTISM PROJECT, INC<br />
KIM SCHUTT-CHARDON<br />
150 N. SUNNYSLOPE RD SUITE 100<br />
BROOKFIELD, WI 53005<br />
County: Waukesha<br />
kim.schutt-chardon@wiautism.com<br />
Phone: (608) 662-9327<br />
Fax: (608) 662-9041<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
06/01/2011 05/31/2011<br />
06/01/2009 05/31/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
05/20/2003<br />
06/01/2012<br />
05/31/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
NO BRANCH LOCATIONS<br />
04/01/2011 03/31/2013<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
06/01/2012 05/31/2014
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 332 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2648<br />
WISCONSIN PSYCHOLOGICAL CENTER/CENTRO<br />
PSICOLOGICO DE WISCONSIN<br />
MARCELO TRINIDAD-CARRILLO<br />
49 KESSEL COURT, #204<br />
FITCHBURG, WI 53711<br />
County: Dane<br />
drtr<strong>in</strong>idad@chorus.net<br />
Phone: (608) 270-1800<br />
Fax: (608) 270-9731<br />
Surveyor: William Rohner<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
02/28/2006<br />
03/01/2009<br />
02/28/2011<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
2000<br />
WISCONSIN PSYCHOTHERAPY AND HEALING<br />
CENTER<br />
KAY PHILLIPS<br />
6333 ODANA ROAD<br />
MADISON, WI 53719<br />
County: Dane<br />
wiscons<strong>in</strong>psychotherapy<strong>in</strong>c@earthl<strong>in</strong>k.net<br />
Phone: (608) 288-8022<br />
Fax: (608) 288-8977<br />
Surveyor: William Rohner<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
09/01/1993<br />
09/01/2010<br />
08/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2016<br />
WOLF FAMILY & CHILD CLINIC<br />
DENNIS K WOLF<br />
12065 W. JANESVILLE ROAD, #200<br />
HALES CORNERS, WI 53130<br />
County: Milwaukee<br />
denniskwolf@aol.com (don't publish)<br />
Phone: (414) 425-2655<br />
Fax: No Number Provided<br />
Surveyor: Demetrius Anderson<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2009 02/28/2011<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/1992<br />
01/01/2009<br />
12/31/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
09/01/2010 08/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/01/2009 12/31/2010
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 333 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2019<br />
WOOD COUNTY HUMAN SERVICES DEPARTMENT<br />
RANDALL AMBROSIUS<br />
2611- 12TH STREET SOUTH<br />
WISCONSIN RAPIDS, WI 54494<br />
County: Wood<br />
rambrosius@co.wood.wi.us<br />
Phone: (715) 421-8849<br />
Fax: (715) 421-2266<br />
Surveyor: Bradley Jahr<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
08/01/1977<br />
07/01/2012<br />
06/30/2014<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic with Telehealth DHS 35<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Day Treatment with Telehealth DHS 75.12<br />
CSAS-Emergency Outpatent with Telehealth DHS 75.05<br />
CSAS-Emergency Outpatient DHS 75.05<br />
CSAS-Outpatient Treatment DHS 75.13<br />
CSAS-Outpatient Treatment with Telehealth DHS 75.13<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 DHS 34.3<br />
<strong>Mental</strong> <strong>Health</strong>-Emergency Service 3 w/Telehealth DHS 34.3<br />
2678<br />
WOOD COUNTY UNIFIED SERVICES<br />
COMPREHENSIVE COMMUNITY SERVICES<br />
KATHY ROETTER<br />
2611 - 12TH AVENUE, SOUTH<br />
WISCONSIN RAPIDS, WI 54494<br />
County: Wood<br />
kroetter@co.wood.wi.us<br />
Phone: (715) 421-8800<br />
Fax: (715) 421-2266<br />
Surveyor: Bradley Jahr<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
08/01/1977<br />
07/01/2012<br />
06/30/2014<br />
Comprehensive Community Services (CCS) DHS 36<br />
2020<br />
WOODLANDS COUNSELING CENTRE, LLC<br />
CHRISTINE E. RAINEY<br />
6506 SCHROEDER ROAD<br />
MADISON, WI 53711<br />
County: Dane<br />
No Email Address Provided<br />
Phone: (608) 274-7800<br />
Fax: No Number Provided<br />
Surveyor: William Rohner<br />
Services<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/1994<br />
07/01/2008<br />
06/30/2010<br />
<strong>Mental</strong> <strong>Health</strong>-Outpatient DHS 61.91<br />
NO BRANCH LOCATIONS<br />
07/01/2012 06/30/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
07/01/2008 06/30/2010
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 334 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2509<br />
WORD OF HOPE MINISTRIES ATODA PROGRAM<br />
PRENTISS MCCLELLAN<br />
2677 N 40TH STREET<br />
MILWAUKEE, WI 53210<br />
County: Milwaukee<br />
pmcclell<strong>and</strong>@wohmke.org<br />
Phone: (414) 447-1965<br />
Fax: (414) 447-1964<br />
Surveyor: Demetrius Anderson<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
03/01/2004<br />
03/01/2012<br />
02/28/2014<br />
CSAS-Outpatient Treatment DHS 75.13<br />
2950<br />
WYALUSING ACADEMY OUTPATIENT CLINIC<br />
MARY BETH SPECHT<br />
601 S BEAUMONT RD<br />
PRAIRIE DU CHIEN, WI 53821<br />
County: Crawford<br />
spechted@cl<strong>in</strong>icarecorp.com<br />
Phone: (608) 326-6481<br />
Fax: (608) 326-6166<br />
Surveyor: Cynthia L<strong>in</strong>dgren<br />
Services<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
11/02/2011<br />
11/02/2011<br />
10/31/2012<br />
<strong>Mental</strong> <strong>Health</strong> Outpatient Cl<strong>in</strong>ic DHS 35<br />
2636<br />
ZCI-1<br />
CHERYL ZIMMERMAN, PHD<br />
524 MAIN STREET, #302<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
ZCI1@ameritech.net<br />
Phone: (262) 632-1780<br />
Fax: (262) 632-0895<br />
Surveyor: Mark Isaacs<br />
Services<br />
NO BRANCH LOCATIONS<br />
03/01/2012 02/28/2014<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
01/10/2006<br />
02/01/2011<br />
01/31/2013<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
NO BRANCH LOCATIONS<br />
11/02/2011 10/31/2012<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013
DEPARTMENT OF HEALTH SERVICES<br />
Division of Quality Assurance<br />
Pr<strong>in</strong>t Date: 08/28/2012<br />
Page 335 of 335<br />
Certification Number/<br />
Certified Provider's Ma<strong>in</strong> Site/<br />
Email/Telephone<br />
2637<br />
ZCI-2<br />
CHERYL ZIMMERMAN, PHD<br />
1717 TAYLOR AVENUE<br />
RACINE, WI 53403<br />
County: Rac<strong>in</strong>e<br />
ZCI1@ameritech.net<br />
Phone: (262) 632-1780<br />
Fax: (262) 632-0895<br />
Surveyor: Mark Isaacs<br />
Services<br />
Community <strong>Substance</strong> <strong>Abuse</strong> <strong>and</strong> <strong>Mental</strong> <strong>Health</strong><br />
Program Certification Directory<br />
By Provider Name & Certification Number<br />
Initial Certification/<br />
Certification Effective/<br />
Certification Expires<br />
01/10/2006<br />
02/01/2011<br />
01/31/2013<br />
CSAS-Day Treatment DHS 75.12<br />
CSAS-Outpatient Treatment DHS 75.13<br />
STATE OF WISCONSIN<br />
Bureau of <strong>Health</strong> Services<br />
PO Box 2969<br />
Madison, WI 53701-2969<br />
Tier/<br />
Branch Beg<strong>in</strong>/<br />
Branch Location(s) End Dates<br />
NO BRANCH LOCATIONS<br />
Adm<strong>in</strong>istrative<br />
Code Chapter Service Beg<strong>in</strong>/End Dates<br />
02/01/2011 01/31/2013<br />
02/01/2011 01/31/2013
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