Healthcare Provider Details

I. General information

NPI: 1689812422
Provider Name (Legal Business Name): IMPACT COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2009
Last Update Date: 02/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 STATE HIGHWAY 70 E
SAINT GERMAIN WI
54558-8800
US

IV. Provider business mailing address

15655 COUNTY ROAD B P.O. BOX 13251
HAYWARD WI
54843-3251
US

V. Phone/Fax

Practice location:
  • Phone: 715-479-8999
  • Fax:
Mailing address:
  • Phone: 715-634-0607
  • Fax: 715-634-0617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number42221700
License Number StateWI

VIII. Authorized Official

Name: JOHN A HINZ
Title or Position: BUSINESS MANAGER
Credential:
Phone: 715-634-0607