=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235779240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONSCIOUS PRACTICE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2020
-----------------------------------------------------
Last Update Date | 05/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 19TH ST N
-----------------------------------------------------
City | LA CROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601-3724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-406-4477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 KING ST STE 218
-----------------------------------------------------
City | LA CROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601-4289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-406-4477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MONICA GORSKI
-----------------------------------------------------
Credential | PMHNP
-----------------------------------------------------
Telephone | 608-406-4477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------