=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114672896
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILWAUKEE COUNSELING CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2022
-----------------------------------------------------
Last Update Date | 02/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14135 N CEDARBURG RD
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53097-1416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-235-0220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3401 N 55TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53216-2807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-770-0751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | DAVID ROBERT ORDAN
-----------------------------------------------------
Credential | M.S., LPC, NCC
-----------------------------------------------------
Telephone | 262-235-0220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------