=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669278651
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIDE THE WAVE COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2025
-----------------------------------------------------
Last Update Date | 12/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136 W GRAND AVE STE 230
-----------------------------------------------------
City | BELOIT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53511-6259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-279-7982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 136 W GRAND AVE STE 230
-----------------------------------------------------
City | BELOIT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53511-6259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-279-7982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID BLOCK
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 815-670-0455
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------