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General NPI Number Information
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NPI Number | 1982821575
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Entity Type | Organization
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Legal Business Name | NORTHWEST COUNSELING AND GUIDANCE - NORTHWEST JOURNEY - SUPERIOR
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 10/22/2009
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Provider Practice Location Address
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Address Line | 1419 HILL AVE STE B
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City | SUPERIOR
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State | WI
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Zip | 54880-1951
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Country | US
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Telephone | 715-395-3805
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Fax | 715-424-5720
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Provider Business Mailing Address
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Address Line | 1412 E SECOND STREET
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City | SUPERIOR
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State | ID
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Zip | 54880
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Country | US
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Telephone | 715-395-3805
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Fax | 715-424-5720
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Authorized Official
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Title or Position | CFO
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Name | MR. NICK KALAMBOKIDIS
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Credential |
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Telephone | 715-327-4402
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 2074
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License Number State | WI
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