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General NPI Number Information
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NPI Number | 1346419082
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Entity Type | Organization
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Legal Business Name | IMPACT COUNSELING SERVICES, LLC
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Dates
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Enumeration Date | 02/27/2008
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Last Update Date | 08/11/2008
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Provider Practice Location Address
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Address Line | 15655 COUNTY ROAD B
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City | HAYWARD
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State | WI
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Zip | 54843-3251
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Country | US
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Telephone | 715-634-0607
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Fax | 715-634-0617
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Provider Business Mailing Address
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Address Line | 15655 COUNTY HWY B P.O. BOX 13251
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City | HAYWARD
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State | WI
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Zip | 54843
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Country | US
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Telephone | 715-634-0607
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Fax | 715-634-0617
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Authorized Official
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Title or Position | DIRECTOR
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Name | MS. RENEE MARIE MILLWOOD
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Credential | MS, LCSW
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Telephone | 715-634-0607
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 42213900
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License Number State | WI
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