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General NPI Number Information
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NPI Number | 1104026665
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Entity Type | Organization
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Legal Business Name | CHRISTIAN COMMUNITY RESOURCES, LLC
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Dates
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Enumeration Date | 07/23/2007
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Last Update Date | 07/23/2007
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Provider Practice Location Address
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Address Line | 2141 ALTOONA AVE SUITE C
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City | EAU CLAIRE
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State | WI
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Zip | 54701-3429
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Country | US
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Telephone | 715-552-7350
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1426
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City | EAU CLAIRE
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State | WI
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Zip | 54702-1426
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Country | US
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Telephone | 715-552-7350
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | MICHAEL LACE
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Credential | PSYD
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Telephone | 715-838-8898
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 33333
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License Number State | WI
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