MEDICARE: HIDDEN PATH COUNSELING, 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

General Provider Information

NPI Number	:	1528683679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIDDEN PATH COUNSELING, LLC

Provider Business Mailing Address
First Line	:	301 CHEROKEE LN
Second Line	:
City	:	FORT ATKINSON
State	:	WI
Zip	:	53538-3006
Country	:	US
Telephone Number	:	608-322-8552
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 S WATER ST E
Second Line	:
City	:	FORT ATKINSON
State	:	WI
Zip	:	53538-2053
Country	:	US
Telephone Number	:	608-322-8552
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	JILL M MALLIN
Credential	:	PHD
Telephone Number	:	608-322-8552

Provider Enumeration Date	:	06/15/2020
Last Update Date	:	06/15/2020

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