Wisconsin Community Mental Health Program Certification ...

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance

Community Mental Health Program Certification Directory By County, City, and Provider Name

STATE OF WISCONSIN Bureau of Health Services

PO Box 2969 Madison, WI 53701-2969

ADAMS FRIENDSHIP

ADAMS COUNTY HEALTH & HUMAN SERVICES COMMUNITY SUPPORT PROGRAM

108 E NORTH ST FRIENDSHIP, WI 53934 County: Adams Surveyor: Elizabeth Secrest

ADAM SHORT adam.short@co.adams.wi.us Phone: (608) 339-4505 Fax: (608) 339-4593

Services 63 MENTAL HEALTH-COMMUNITY SUPPORT PROGRAM

Adm Code DHS 63

3243

Initial Cert: Cert Eff: Cert Exp:

01/17/2019 08/01/2023 Non-Expiring

Service Begin 08/01/2023

ADAMS COUNTY HEALTH & HUMAN SERVICES DEPT COMPREHENSIVE COMMUNITY SERVICES

108 E NORTH STREET FRIENDSHIP, WI 53934 County: Adams Surveyor: Elizabeth Secrest

DIANE OSBORN dosborn@co.adams.wi.us Phone: (608) 339-4505 Fax: (608) 339-4585

2810

Initial Cert: Cert Eff: Cert Exp:

12/10/2008 08/01/2023 Non-Expiring

CCS Affiliation: CENTRAL WISCONSIN HEALTH PARTNERSHIP V2

Services 36 CCS REGIONAL MODEL SHARED SERVICES

Begin: 01/01/2016

Adm Code DHS 36

Service Begin 08/01/2023

ADAMS COUNTY HEALTH AND HUMAN SERVICES DEPARTMENT

108 E NORTH STREET FRIENDSHIP, WI 53934 County: Adams Surveyor: Elizabeth Secrest

ADAM SHORT adam.short@co.adams.wi.us Phone: (608) 339-4505 Fax: (608) 339-4585

Crisis Intervention Services Regional Designation

BEHAVIORAL HEALTH TRAINING PARTNERSHIP BRIDGEWAY ADULT CRISIS STABILIZATION CBRF NORTHWEST CONNECTIONS SHARED CALL AND CRISIS SERVICE Services 34.3 MENTAL HEALTH-EMERGENCY SERVICE 3 35 MENTAL HEALTH OUTPATIENT CLINIC 75.15 CSUS-INTERVENTION SERVICE AND INTOXICATED DRIVER 75.15(8) CSUS-INTOXICATED DRIVER PROGRAM ASSESSMENT SER 75.49 CSUS-OUTPATIENT SUBSTANCE USE TREATMENT SERVICE

Begin 01/01/2020 01/01/2020 01/01/2020 Adm Code DHS 34.3 DHS 35 DHS 75.15 DHS 75.15(8) DHS 75.49

Non-Certified School Setting(s) ADAMS/FRIENDSHIP HIGH SCHOOL, 1109 E NORTH ST, ADAMS, WI 53910 ADAMS/FRIENDSHIP MIDDLE SCHOOL, 420 N MAIN ST, ADAMS, WI 53910

1253

Initial Cert: Cert Eff: Cert Exp:

09/01/1990 10/01/2022 Non-Expiring

Lead

Service Begin 10/01/2022 10/01/2022 10/01/2022 10/01/2022 10/01/2022

Setting Begin/End Dates 10/01/2022 10/01/2022

09/19/2023

Page 1 of 239

Mental Health Program Directory By County, City, and Provider Name

FAMILY HEALTH LA CLINICA ROCHE-A-CRI BEHAVIORAL HEALTH & RECOVERY CENTER

302 W LAKE ST FRIENDSHIP, WI 53934 County: Adams Surveyor: Elizabeth Secrest

JOELLEN M. KOZLOWSKI JoEllen.Kozlowski@ Phone: (608) 474-4355 Fax: () -

3245

Initial Cert: Cert Eff: Cert Exp:

03/14/2019 04/01/2022 Non-Expiring

Services 75.50 CSUS-OUTPATIENT INTEGRATED BEHAVIORAL HEALTH TREA

Adm Code DHS 75.50

Service Begin 10/01/2022

09/19/2023

Page 2 of 239

Mental Health Program Directory By County, City, and Provider Name

ASHLAND COUNTY CCS

630 SANBORN AVENUE ASHLAND, WI 54806 County: Ashland Surveyor: Janel L Benedum

ASHLAND ASHLAND

VALERIE LEVNO valerie.levno@co.ashland.wi.us Phone: (715) 628-7004 Fax: (715) 682-7176

CCS Affiliation: ASHLAND/BAYFIELD CCS REGION

Services 36 CCS REGIONAL MODEL SHARED SERVICES

Begin: 05/01/2019

Adm Code DHS 36

3055

Initial Cert: Cert Eff: Cert Exp:

01/01/2015 08/01/2023 Non-Expiring

Service Begin 08/01/2023

ASHLAND COUNTY COMMUNITY SUPPORT PROGRAM

630 SANBORN AVENUE ASHLAND, WI 54806 County: Ashland Surveyor: Janel L Benedum

VAL LEVNO valerie.levno@co.ashland.wi.us Phone: (715) 628-7004 Fax: (715) 682-7176

Services 63 MENTAL HEALTH-COMMUNITY SUPPORT PROGRAM

Adm Code DHS 63

3258

Initial Cert: Cert Eff: Cert Exp:

05/31/2019 08/01/2023 Non-Expiring

Service Begin 08/01/2023

ASHLAND COUNTY HEALTH AND HUMAN SERVICES/NORTHLAND COUNSELING SERVICES

1619 WEST THIRD STREET ASHLAND, WI 54806 County: Ashland Surveyor: Janel L Benedum

CAROL LUND northland006@ Phone: (715) 682-2144 Fax: (715) 682-2148

Crisis Intervention Services Regional Designation

FAMILY SERVICES SHARED CALL SERVICE

Services 34.3 MENTAL HEALTH-EMERGENCY SERVICE 3

Begin 01/01/2020

Adm Code DHS 34.3

2639

Initial Cert: Cert Eff: Cert Exp:

01/26/2006 08/01/2023 Non-Expiring

Lead

Service Begin 08/01/2023

BAD RIVER AODA PROGRAM

53585 NOKOMIS RD ASHLAND, WI 54806 County: Ashland Surveyor: Janel L Benedum

ROBERT HOULE r.houle@ Phone: (715) 682-7137 Fax: (715) 685-7866

Services 75.15 CSUS-INTERVENTION SERVICE AND INTOXICATED DRIVER 75.15(8) CSUS-INTOXICATED DRIVER PROGRAM ASSESSMENT SER 75.49 CSUS-OUTPATIENT SUBSTANCE USE TREATMENT SERVICE

Adm Code DHS 75.15 DHS 75.15(8) DHS 75.49

2728

Initial Cert: Cert Eff: Cert Exp:

02/01/2007 03/01/2023 Non-Expiring

Service Begin 06/14/2023 06/14/2023 03/01/2023

09/19/2023

Page 3 of 239

Mental Health Program Directory By County, City, and Provider Name

BEHAVIORAL HEALTH SERVICES OF MEMORIAL MEDICAL CENTER

1615 MAPLE LANE ASHLAND, WI 54806 County: Ashland Surveyor: Janel L Benedum

THOMAS JENSEN tjjensen@ Phone: (715) 685-5400 Fax: (715) 685-5102

2154

Initial Cert: Cert Eff: Cert Exp:

10/01/1999 10/01/2021 Non-Expiring

Services 35 MENTAL HEALTH OUTPATIENT CLINIC 61.71 MENTAL HEALTH-INPATIENT 61.75 MENTAL HEALTH-DAY TREATMENT 75.49 CSUS-OUTPATIENT SUBSTANCE USE TREATMENT SERVICE

Adm Code DHS 35 DHS 61.71 DHS 61.75 DHS 75.49

Service Begin 10/01/2021 10/01/2021 10/01/2021 10/01/2022

Tier

Branch Location(s)

1 NORTHLAND COLLEGE, 1411 ELLIS AVE, ASHLAND, WI 54806

3 ASHLAND MIDDLE SCHOOL, 203 - 11TH STREET EAST, ASHLAND, WI 54806 3 LAKE SUPERIOR PRIMARY SCHOOL, 1101 BINSFIELD ROAD, ASHLAND, WI 54806 3 DRUMMOND AREA SCHOOL DISTRICT, 52440 EASTERN AVE, DRUMMOND, WI 54832 3 SCHOOL DISTRICT OF MELLEN, 420 S MAIN ST, MELLEN, WI 54546

Branch Begin/End Dates 10/01/2021 10/01/2021 10/01/2021 10/01/2021 05/09/2022

NORTHLAND COUNSELING YOUTH CRISIS STABILIZATION FACILITY

1613 W 3RD STREET ASHLAND, WI 54806 County: Ashland Surveyor: Janel L Benedum

CAROL LUND northland006@ Phone: (715) 373-0160 Fax: (715) 373-0162

Services 50 MENTAL HEALTH-YOUTH CRISIS STABILIZATION FACILITY

Adm Code DHS 50

3338

Initial Cert: Cert Eff: Cert Exp:

04/01/2022 04/01/2022 Non-Expiring

Service Begin 04/01/2022

09/19/2023

Page 4 of 239

Mental Health Program Directory By County, City, and Provider Name

BARRON BARRON

BARRON COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES

335 EAST MONROE AVE ROOM 338 BARRON, WI 54812 County: Barron Surveyor: Janel L Benedum

ANN HAY ann.hay@co.barron.wi.us Phone: (715) 537-6134 Fax: (715) 537-6848

Crisis Intervention Services Regional Designation

NORTHWEST CONNECTIONS SHARED CALL AND CRISIS SERVICE

Services 34.3 MENTAL HEALTH-EMERGENCY SERVICE 3 75.49 CSUS-OUTPATIENT SUBSTANCE USE TREATMENT SERVICE

Begin 01/01/2020

Adm Code DHS 34.3 DHS 75.49

2640

Initial Cert: Cert Eff: Cert Exp:

01/01/2006 11/01/2021 Non-Expiring

Lead

Service Begin 11/01/2021 10/01/2022

BARRON COUNTY DHHS COMPREHENSIVE COMMUNITY SERVICES

335 E MONROE AVE BARRON, WI 54812 County: Barron Surveyor: Janel L Benedum

ANN HAY ann.hay@co.barron.wi.us Phone: (715) 537-5691 Fax: (715) 537-6848

CCS Affiliation: BEST CCS

Services 36 CCS REGIONAL MODEL SHARED SERVICES

Begin: 01/01/2019

Adm Code DHS 36

3230

Initial Cert: Cert Eff: Cert Exp:

01/01/2019 08/01/2023 Non-Expiring

Service Begin 08/01/2023

LSS BARRON AREA RESIDENTIAL TREATMENT

BARRONETT

806 29 1/2 AVENUE BARRONETT, WI 54813 County: Barron Surveyor: Janel L Benedum

SHELLEY HAMMES shelley.hammes@ Phone: (715) 371-0331 Fax: () -

Services 75.54 CSUS-MEDICALLY MONITORED RESIDENTIAL TREATMENT SE

Adm Code DHS 75.54

3499

Initial Cert: Cert Eff: Cert Exp:

08/16/2023 08/16/2023 Non-Expiring

Service Begin 08/16/2023

CUMBERLAND

CUMBERLAND MEMORIAL HOSPITAL INC DBA CUMBERLAND HEALTHCARE

1110 7TH AVENUE CUMBERLAND, WI 54829 County: Barron Surveyor: Janel L Benedum

KARL ADER kader@ Phone: (715) 822-7530 Fax: (715) 822-7221

Services 35 MENTAL HEALTH OUTPATIENT CLINIC

Adm Code DHS 35

3148

Initial Cert: Cert Eff: Cert Exp:

10/06/2016 08/01/2023 Non-Expiring

Service Begin 08/01/2023

Non-Certified School Setting(s) CUMBERLAND ELEMENTARY SCHOOL, 1530 2ND AVE, CUMBERLAND, WI 54829

Setting Begin/End Dates 08/01/2023

09/19/2023

Page 5 of 239

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