Healthcare Provider Details

I. General information

NPI: 1669103057
Provider Name (Legal Business Name): KELLY THOMACK COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 W GRANDE MARKET DR STE M
APPLETON WI
54913-8506
US

IV. Provider business mailing address

5601 W GRANDE MARKET DR STE M
APPLETON WI
54913-8506
US

V. Phone/Fax

Practice location:
  • Phone: 920-215-1105
  • Fax: 937-606-3077
Mailing address:
  • Phone: 920-418-1150
  • Fax: 937-606-3077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KELLY THOMACK
Title or Position: OWNER
Credential: LPCC
Phone: 920-418-1150