Healthcare Provider Details

I. General information

NPI: 1174913156
Provider Name (Legal Business Name): BRILL COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4433 N OAKLAND AVE
SHOREWOOD WI
53211-1600
US

IV. Provider business mailing address

4433 N OAKLAND AVE
SHOREWOOD WI
53211-1600
US

V. Phone/Fax

Practice location:
  • Phone: 414-906-1445
  • Fax: 414-906-1445
Mailing address:
  • Phone: 414-906-1445
  • Fax: 414-906-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7969123
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3677123
License Number StateWI

VIII. Authorized Official

Name: MARY JO BRILL
Title or Position: PSYCHOTHERAPIST
Credential: LCSW
Phone: 414-906-1445