Healthcare Provider Details

I. General information

NPI: 1417121666
Provider Name (Legal Business Name): IMPACT COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 08/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 S ANDERSON ST
RHINELANDER WI
54501-3447
US

IV. Provider business mailing address

15655 CO HWY B PO BOX 13251
HAYWARD WI
54843
US

V. Phone/Fax

Practice location:
  • Phone: 715-362-6390
  • Fax:
Mailing address:
  • Phone: 715-634-0607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number43005300
License Number StateWI

VIII. Authorized Official

Name: RENEE M MILLWOOD
Title or Position: DIRECTOR
Credential:
Phone: 715-634-0607