Healthcare Provider Details

I. General information

NPI: 1528507605
Provider Name (Legal Business Name): FULL POTENTIAL COACHING COUNSELING CONSULTING OF WI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 E BROADWAY SUITE 135
MADISON WI
53716-4103
US

IV. Provider business mailing address

4710 E BROADWAY SUITE 135
MADISON WI
53716-4103
US

V. Phone/Fax

Practice location:
  • Phone: 608-205-2294
  • Fax: 608-719-5033
Mailing address:
  • Phone: 608-205-2294
  • Fax: 608-719-5033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14034
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2878
License Number StateWI

VIII. Authorized Official

Name: TED IZYDOR
Title or Position: OWNER
Credential: MS, LPC, CSAC
Phone: 608-205-2294