=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578814026
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINDA SCHWALLIE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2012
-----------------------------------------------------
Last Update Date | 09/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 926 WILLARD DR
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54304-5071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-621-3036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 MIRAMAR DR
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54301-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-621-3036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. LINDA SCHWALLIE
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 920-621-3036
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 67-124
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------