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General NPI Number Information
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NPI Number | 1366004384
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Entity Type | Organization
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Legal Business Name | PINE COUNSELING INC.
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Dates
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Enumeration Date | 06/29/2019
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Last Update Date | 12/08/2019
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Provider Practice Location Address
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Address Line | 204 S ORANGE ST
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City | RICHLAND CENTER
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State | WI
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Zip | 53581-2170
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Country | US
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Telephone | 931-982-4832
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Fax | 608-383-1480
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Provider Business Mailing Address
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Address Line | 204 S ORANGE ST
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City | RICHLAND CENTER
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State | WI
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Zip | 53581-2170
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Country | US
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Telephone | 931-982-4832
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Fax | 608-383-1480
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Authorized Official
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Title or Position | BOARD MEMBER
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Name | ELIJAH LAKE KRAMER
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Credential | SAC-IT
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Telephone | 920-285-0453
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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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 |
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License Number State |
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