Healthcare Provider Details

I. General information

NPI: 1770776429
Provider Name (Legal Business Name): ELAINE THERESE CONWAY MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELAINE CONWAY MELLEN

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 S CLAY ST
GREEN BAY WI
54301-3419
US

IV. Provider business mailing address

3900 W BROWN DEER RD SUITE 200
BROWN DEER WI
53209-1220
US

V. Phone/Fax

Practice location:
  • Phone: 920-819-6570
  • Fax:
Mailing address:
  • Phone: 414-540-2170
  • Fax: 414-540-2171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3537-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: