Healthcare Provider Details

I. General information

NPI: 1235990698
Provider Name (Legal Business Name): LAVENDER SKIES COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 03/14/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1794 ALLOUEZ AVE. SUITE C, NUMBER 243
GREEN BAY WI
54311-6281
US

IV. Provider business mailing address

1794 ALLOUEZ AVE. SUITE C, NUMBER 243
GREEN BAY WI
54311
US

V. Phone/Fax

Practice location:
  • Phone: 920-367-4025
  • Fax:
Mailing address:
  • Phone: 920-367-4025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CINDY L FONSECA
Title or Position: MENTAL HEALTH THERAPIST
Credential:
Phone: 920-367-4025