Healthcare Provider Details

I. General information

NPI: 1366556359
Provider Name (Legal Business Name): BLUE WATERS FAMILY COUNSELING, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 WASHINGTON ST
MANITOWOC WI
54220-4847
US

IV. Provider business mailing address

2215 WASHINGTON ST
MANITOWOC WI
54220-4847
US

V. Phone/Fax

Practice location:
  • Phone: 920-683-3911
  • Fax: 920-683-3411
Mailing address:
  • Phone: 920-683-3911
  • Fax: 920-683-3411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: DIANE M BERRY
Title or Position: DIRECTOR
Credential: MSW LCSW JD
Phone: 920-683-3911