Healthcare Provider Details

I. General information

NPI: 1942875323
Provider Name (Legal Business Name): BALANCED SOLUTION THERAPIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 W LAWRENCE ST # 105
APPLETON WI
54911-5834
US

IV. Provider business mailing address

621 W LAWRENCE ST # 105
APPLETON WI
54911-5834
US

V. Phone/Fax

Practice location:
  • Phone: 920-277-9085
  • Fax:
Mailing address:
  • Phone: 920-277-9085
  • Fax:

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: KRISTAL K WICHMAN
Title or Position: OWNER
Credential: LCSW
Phone: 920-277-9085