Healthcare Provider Details

I. General information

NPI: 1396541942
Provider Name (Legal Business Name): EQUIPOISE PROFESSIONAL COUNSELING AND PERSONAL COACHING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 S MONROE AVE
GREEN BAY WI
54301-3002
US

IV. Provider business mailing address

1208 S MONROE AVE
GREEN BAY WI
54301-3002
US

V. Phone/Fax

Practice location:
  • Phone: 920-327-2596
  • Fax:
Mailing address:
  • Phone: 920-327-2596
  • 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 Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: DAVID W PALUCH
Title or Position: REGISTERED AGENT
Credential: RN (BSN) LPC (MS)
Phone: 920-327-2596