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General NPI Number Information
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NPI Number | 1962896068
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Entity Type | Organization
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Legal Business Name | FIRST LIGHT COUNSELING SERVICES LLC
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Dates
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Enumeration Date | 03/26/2015
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Last Update Date | 03/26/2015
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Provider Practice Location Address
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Address Line | W6385 FIRELANE 8
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City | MENASHA
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State | WI
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Zip | 54952-9746
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Country | US
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Telephone | 920-739-9230
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Fax |
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Provider Business Mailing Address
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Address Line | W6385 FIRELANE 8
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City | MENASHA
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State | WI
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Zip | 54952-9746
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Country | US
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Telephone | 920-739-9230
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | LAUREL HOWARD-BOARDMAN
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Credential | MSSW,LCSW
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Telephone | 920-739-9230
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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 | 7294-123
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License Number State | WI
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