Healthcare Provider Details

I. General information

NPI: 1497908099
Provider Name (Legal Business Name): PSYCHOLOGICAL RESOURCE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 02/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 N 4TH ST SUITE 108
TOMAHAWK WI
54487-2152
US

IV. Provider business mailing address

1218 N 4TH ST SUITE 108
TOMAHAWK WI
54487-2152
US

V. Phone/Fax

Practice location:
  • Phone: 715-224-2100
  • Fax: 715-224-2106
Mailing address:
  • Phone: 715-224-2100
  • Fax: 715-224-2106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2806
License Number StateWI

VIII. Authorized Official

Name: LAURA ANNE ELCOATE
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 715-224-2100