Healthcare Provider Details

I. General information

NPI: 1467626606
Provider Name (Legal Business Name): IMPACT COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 08/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 ELLIS AVE SUITE 1
ASHLAND WI
54806-1667
US

IV. Provider business mailing address

15655 CO HWY B PO BOX 13251
HAYWARD WI
54843
US

V. Phone/Fax

Practice location:
  • Phone: 715-682-3523
  • Fax:
Mailing address:
  • Phone: 715-634-0607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number43008600
License Number StateWI

VIII. Authorized Official

Name: RENEE M MILLWOOD
Title or Position: DIRECTOR
Credential: MS, LCSW
Phone: 715-634-0607