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General NPI Number Information
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NPI Number | 1104053701
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Entity Type | Organization
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Legal Business Name | INTEGRATED COUNSELING CENTER LLC
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Dates
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Enumeration Date | 06/22/2009
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Last Update Date | 06/22/2009
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Provider Practice Location Address
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Address Line | N6687 WRIGHTWAY DR STE D
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City | FOND DU LAC
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State | WI
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Zip | 54937-8433
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Country | US
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Telephone | 920-929-9140
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Fax | 920-929-9142
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Provider Business Mailing Address
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Address Line | N6687 WRIGHTWAY DR STE D
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City | FOND DU LAC
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State | WI
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Zip | 54937-8433
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Country | US
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Telephone | 920-929-9140
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Fax | 920-929-9142
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Authorized Official
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Title or Position | OWNER
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Name | ROSONNA SUE COMERS
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Credential | LCSW
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Telephone | 920-929-9140
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 29-036
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2270-057
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 7209-123
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License Number State | WI
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 7003-123
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License Number State | WI
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