Healthcare Provider Details

I. General information

NPI: 1164133781
Provider Name (Legal Business Name): EMILY BELONGIA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W6144 AEROTECH DR
APPLETON WI
54914-7503
US

IV. Provider business mailing address

1242 FATIMA ST
MENASHA WI
54952-1419
US

V. Phone/Fax

Practice location:
  • Phone: 920-733-2065
  • Fax:
Mailing address:
  • Phone: 920-733-2065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7152226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: