MEDICARE: CLEARWATER COUNSELING AND PERSONAL GROWTH CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health	1203	WI

General Provider Information

NPI Number	:	1205979168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEARWATER COUNSELING AND PERSONAL GROWTH CENTER, INC.

Provider Business Mailing Address
First Line	:	4330 GOLF TER
Second Line	:	SUITE 213M
City	:	EAU CLAIRE
State	:	WI
Zip	:	54701-4683
Country	:	US
Telephone Number	:	715-832-4060
Fax Number	:	715-832-5914

Provider Business Practice Location Address
First Line	:	4330 GOLF TER
Second Line	:	SUITE 213M
City	:	EAU CLAIRE
State	:	WI
Zip	:	54701-4683
Country	:	US
Telephone Number	:	715-832-4060
Fax Number	:	715-832-5914

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JANICE SUSAN O'CONNOR
Credential	:	M.S.W., L.C.S.W.
Telephone Number	:	715-832-4060

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	07/08/2007

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