Mental Health and Substance Abuse Programs in alphabetical

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DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Print Date: 08/28/2012 Page 10 of 335 Certification Number/ Certified Provider's Main Site/ Email/Telephone 2650 AFFILIATED WELLNESS GROUP, LLC JENNIFER JONES 2301 SUN VALLEY DRIVE, #209 DELAFIELD, WI 53018 County: Waukesha Bethechange8@hotmail.com Phone: (262) 646-8288 Fax: (262) 646-8255 Surveyor: Mark Isaacs Services Community Substance Abuse and Mental Health Program Certification Directory By Provider Name & Certification Number Initial Certification/ Certification Effective/ Certification Expires 02/27/2006 03/01/2011 02/28/2013 Mental Health Outpatient Clinic DHS 35 CSAS-Outpatient Treatment DHS 75.13 1020 AFFINITY HOUSE ANITA KUSTER 3042 KILBOURNE AVENUE EAU CLAIRE, WI 54703 County: Eau Claire akuster00@lsswis.org Phone: (715) 833-0436 Fax: (715) 833-1505 Surveyor: Polly Wong Services STATE OF WISCONSIN Bureau of Health Services PO Box 2969 Madison, WI 53701-2969 Tier/ Branch Begin/ Branch Location(s) End Dates NO BRANCH LOCATIONS Administrative Code Chapter Service Begin/End Dates 03/01/1992 03/01/2012 02/28/2014 CSAS-Transitional Residential DHS 75.14 2651 AFFINITY MEDICAL GROUP - BEHAVIORAL HEALTH TINA LECHNIR 1531 S MADISON ST, #580 APPLETON, WI 54915 County: Outagamie tlechnirb @affinityhealth.org Phone: (920) 730-4411 Fax: (920) 730-5481 Surveyor: Frank Bellaire Services NO BRANCH LOCATIONS 03/01/2011 02/28/2013 03/01/2011 02/28/2013 Administrative Code Chapter Service Begin/End Dates 01/20/2005 11/01/2011 10/31/2013 Mental Health Outpatient Clinic DHS 35 03/01/2012 02/28/2014 AFFINITY MEDICAL GROUP-BEHAVIORAL HEALTH Tier 1 2601 FIELDCREST 11/01/2011 KAUKAUNA, WI 54130 10/31/2013 AFFINITY MEDICAL GROUP-BEHAVIORAL HEALTH Tier 1 200 PATRIOT DRIVE 11/01/2011 LITTLE CHUTE, WI 54140 10/31/2013 AFFINITY MEDICAL GROUP-BEHAVIORAL HEALTH Tier 1 1855 S KOELLER 11/01/2011 OSHKOSH, WI 54902 10/31/2013 CALUMET MEDICAL CENTER CLINIC Tier 1 618 MEMORIAL DRIVE 11/01/2011 CHILTON, WI 53014 10/31/2013 Administrative Code Chapter Service Begin/End Dates 11/01/2011 10/31/2013
DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Print Date: 08/28/2012 Page 11 of 335 Certification Number/ Certified Provider's Main Site/ Email/Telephone 1022 AGAPE RECOVERY CENTER PATRICIA A GRAMKE 201 N PINE BURLINGTON, WI 53105 County: Racine agape1995@att.net Phone: (262) 767-0441 Fax: (262) 767-9072 Surveyor: William Rohner Services Community Substance Abuse and Mental Health Program Certification Directory By Provider Name & Certification Number Initial Certification/ Certification Effective/ Certification Expires 04/01/1994 04/01/2011 03/31/2013 CSAS-Outpatient Treatment DHS 75.13 2226 AGNESIAN HEALTHCARE DBA DOLL AND ASSOCIATES BETH ROGERS-DOLL 40 CAMELOT DRIVE FOND DU LAC, WI 54935 County: Fond Du Lac brdoll@dollandassociates.com Phone: (920) 907-8206 Fax: (920) 907-8209 Surveyor: William Goehring Services STATE OF WISCONSIN Bureau of Health Services PO Box 2969 Madison, WI 53701-2969 Tier/ Branch Begin/ Branch Location(s) End Dates NO BRANCH LOCATIONS Administrative Code Chapter Service Begin/End Dates 07/05/2000 07/01/2011 06/30/2013 Mental Health Outpatient Clinic DHS 35 1753 AGNESIAN HEALTHCARE, D.B.A. PSYCHIATRIC ASSOCIATES JIM SALASEK 200 FRONT STREET, #3D BEAVER DAM, WI 53916 County: Dodge salasekj@agnesian.com Phone: (920) 885-2780 Fax: (920) 885-2788 Surveyor: William Goehring Services NO BRANCH LOCATIONS 04/01/2011 03/31/2013 Administrative Code Chapter Service Begin/End Dates 10/01/1984 07/01/2012 06/30/2014 Mental Health Outpatient Clinic DHS 35 CSAS-Outpatient Treatment DHS 75.13 NO BRANCH LOCATIONS 07/01/2011 06/30/2013 Administrative Code Chapter Service Begin/End Dates 07/01/2012 06/30/2014 07/01/2012 06/30/2014
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Mental Health and Substance Abuse Programs in alphabetical

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