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General NPI Number Information
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NPI Number | 1548463961
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Entity Type | Organization
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Legal Business Name | QUAKER VALLEY COUNSELING SERVICES
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Dates
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Enumeration Date | 06/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | E1475 OWENS DRIVE
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City | LA VALLE
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State | WI
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Zip | 53941-9529
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Country | US
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Telephone | 608-985-8187
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Fax |
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Provider Business Mailing Address
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Address Line | E1475 OWENS DRIVE
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City | LA VALLE
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State | WI
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Zip | 53941-9529
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Country | US
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Telephone | 608-985-8187
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Fax |
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Authorized Official
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Title or Position | PSYCHOTHERAPIST
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Name | MYRON MICKELSON
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Credential | LCSW
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Telephone | 608-985-7181
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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 | 2350 - 123
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License Number State | WI
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