Healthcare Provider Details

I. General information

NPI: 1023640695
Provider Name (Legal Business Name): DRIFTLESS COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 E JEFFERSON ST
VIROQUA WI
54665-1613
US

IV. Provider business mailing address

247 5TH AVE
VIROQUA WI
54665-1815
US

V. Phone/Fax

Practice location:
  • Phone: 608-606-6789
  • Fax:
Mailing address:
  • Phone: 608-606-6789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHRIS RUDER
Title or Position: DIRECTOR
Credential: LMFT
Phone: 608-606-6789