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General NPI Number Information
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NPI Number | 1518328277
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Entity Type | Organization
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Legal Business Name | INTEGRATED LIFE COUNSELING CENTER, LLC
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Dates
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Enumeration Date | 03/09/2016
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Last Update Date | 03/09/2016
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Provider Practice Location Address
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Address Line | 215 N MAIN ST 205
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City | WEST BEND
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State | WI
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Zip | 53095-3347
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Country | US
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Telephone | 262-416-2922
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Fax |
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Provider Business Mailing Address
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Address Line | 265 TERRACE DR
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City | WEST BEND
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State | WI
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Zip | 53095-4748
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Country | US
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Telephone | 262-416-2922
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Fax |
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Authorized Official
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Title or Position | SOCIAL WORKER, LCSW
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Name | HADWAT SANKARI
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Credential | LCSW
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Telephone | 262-416-2922
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 7824-123
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License Number State | WI
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