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General NPI Number Information
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NPI Number | 1134355308
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Entity Type | Organization
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Legal Business Name | CEDAR CREEK COUNSELING, S.C.
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Dates
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Enumeration Date | 06/02/2009
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Last Update Date | 09/09/2015
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Provider Practice Location Address
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Address Line | 1035 W GLEN OAKS LN SUITE 110
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City | MEQUON
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State | WI
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Zip | 53092-3392
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Country | US
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Telephone | 262-240-0299
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Fax | 262-240-0308
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Provider Business Mailing Address
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Address Line | 1035 W GLEN OAKS LN SUITE 110
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City | MEQUON
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State | WI
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Zip | 53092-3392
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Country | US
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Telephone | 262-240-0299
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Fax | 262-240-0308
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. BYRON C BLOEMER
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Credential | PH.D.
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Telephone | 262-240-0299
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 057-2140
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License Number State | WI
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