=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770753915
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARRIAGE & FAMILY THERAPY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2008
-----------------------------------------------------
Last Update Date | 03/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 735 E WALNUT ST
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-432-8777
-----------------------------------------------------
Fax | 920-435-0749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 735 E WALNUT ST
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-432-8777
-----------------------------------------------------
Fax | 920-435-0749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE ADMIN
-----------------------------------------------------
Name | MOLLY ROSE CREVIER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-432-8777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------