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General NPI Number Information
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NPI Number | 1720237373
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Entity Type | Organization
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Legal Business Name | CRYSTAL LAKE COUNSELING, LLC
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Dates
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Enumeration Date | 09/18/2008
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Last Update Date | 09/18/2008
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Provider Practice Location Address
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Address Line | 1821 1 1/2 STREET
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City | COMSTOCK
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State | WI
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Zip | 54826
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Country | US
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Telephone | 715-822-2980
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Fax | 715-822-2205
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Provider Business Mailing Address
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Address Line | 1821 1 1/2 STREET P.O. BOX 27
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City | COMSTOCK
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State | WI
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Zip | 54826
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Country | US
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Telephone | 715-822-2980
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Fax | 715-822-2205
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Authorized Official
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Title or Position | CLINIC OWNER AND DIRECTOR
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Name | MS. DEBRA JILL SEVERSON
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Credential | MS LPC
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Telephone | 715-822-2980
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 2766
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License Number State | WI
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