Healthcare Provider Details

I. General information

NPI: 1982000154
Provider Name (Legal Business Name): WING OF EAGLES CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 N MADISON ST SUITE 4
GREEN BAY WI
54301-5103
US

IV. Provider business mailing address

217 N MADISON ST SUITE 4
GREEN BAY WI
54301-5103
US

V. Phone/Fax

Practice location:
  • Phone: 920-227-7078
  • Fax: 920-273-8847
Mailing address:
  • Phone: 920-227-7078
  • Fax: 920-273-8847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: LESLIE C OUSLEY
Title or Position: COUNSELOR
Credential: MA LPC
Phone: 920-228-3199