Healthcare Provider Details

I. General information

NPI: 1649354077
Provider Name (Legal Business Name): WELLNESS COUNSELING CENTER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W COLLEGE AVE SUITE 815
APPLETON WI
54911-5770
US

IV. Provider business mailing address

103 W COLLEGE AVE SUITE 815
APPLETON WI
54911-5770
US

V. Phone/Fax

Practice location:
  • Phone: 920-733-1992
  • Fax: 920-733-1866
Mailing address:
  • Phone: 920-733-1992
  • Fax: 920-733-1866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1982
License Number StateWI

VIII. Authorized Official

Name: CARY BACKENGER
Title or Position: PARTNER/PSYCHO THERAPIST
Credential: MS,CADAIII,CEDS,LPC
Phone: 920-733-1992