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General NPI Number Information
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NPI Number | 1740520345
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Entity Type | Organization
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Legal Business Name | IMPACT CHILD AND FAMILY THERAPIES INC
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Dates
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Enumeration Date | 02/20/2013
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Last Update Date | 02/20/2013
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Provider Practice Location Address
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Address Line | 829 S GREEN BAY RD SUITE 108
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City | MOUNT PLEASANT
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State | WI
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Zip | 53406-4058
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Country | US
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Telephone | 262-497-6212
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Fax |
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Provider Business Mailing Address
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Address Line | 829 S GREEN BAY RD SUITE 108
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City | MOUNT PLEASANT
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State | WI
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Zip | 53406-4058
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Country | US
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Telephone | 262-497-6212
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Fax |
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Authorized Official
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Title or Position | CO DIRECTOR AND EXECUTIVE OFFICER
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Name | MR. WILLIAM PAUL STEWART
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Credential | LCSW
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Telephone | 847-275-9498
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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 | 7963-123
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License Number State | WI
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