Healthcare Provider Details

I. General information

NPI: 1093869588
Provider Name (Legal Business Name): INNOVATIVE COUNSELING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 6TH ST INNOVATIVE COUNSELING INC
GREEN BAY WI
54304-2252
US

IV. Provider business mailing address

1499 6TH ST INNOVATIVE COUNSELING INC
GREEN BAY WI
54304-2252
US

V. Phone/Fax

Practice location:
  • Phone: 920-497-6161
  • Fax: 920-498-0476
Mailing address:
  • Phone: 920-497-6161
  • Fax: 920-498-0476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2283
License Number StateWI

VIII. Authorized Official

Name: MS. CYNTHIA RAE THOMAS
Title or Position: CLINICAL DIRECTOR
Credential: MSW ACSW
Phone: 920-497-6161