MEDICARE: ENTRUSTED COUNSELING SERVICES, LLC

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	251S00000X	Community/Behavioral Health Agency	7919-123	WI

General Provider Information

NPI Number	:	1477894244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENTRUSTED COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	2317 WEBSTER ST
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53403-3056
Country	:	US
Telephone Number	:	262-960-1548
Fax Number	:

Provider Business Practice Location Address
First Line	:	2317 WEBSTER ST
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53403-3056
Country	:	US
Telephone Number	:	262-960-1548
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	MS. MILDRED MARIE SPANN
Credential	:	LCSW
Telephone Number	:	262-960-1548

Provider Enumeration Date	:	03/04/2013
Last Update Date	:	03/04/2013

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