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General NPI Number Information
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NPI Number | 1790958106
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Entity Type | Organization
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Legal Business Name | FAMILY ACHIEVEMENT CLINIC S C
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Dates
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Enumeration Date | 04/07/2008
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Last Update Date | 04/07/2008
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Provider Practice Location Address
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Address Line | 24 S MAIN ST
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City | OCONOMOWOC
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State | WI
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Zip | 53066-5226
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Country | US
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Telephone | 262-567-4560
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Fax | 262-567-4870
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Provider Business Mailing Address
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Address Line | 24 S MAIN ST
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City | OCONOMOWOC
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State | WI
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Zip | 53066-5226
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Country | US
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Telephone | 262-567-4560
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Fax | 262-567-4870
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. MICHAEL M CORNALE
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Credential | MS
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Telephone | 262-567-4560
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 1313
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License Number State | WI
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