MEDICARE: STILLWATER COUNSELING CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TP2701X	Group Psychotherapy Psychologist	1881	WI

General Provider Information

NPI Number	:	1053474510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STILLWATER COUNSELING CENTER

Provider Business Mailing Address
First Line	:	933 N MAYFAIR RD
Second Line	:	SUITE 303
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-3432
Country	:	US
Telephone Number	:	414-456-9929
Fax Number	:	414-456-9994

Provider Business Practice Location Address
First Line	:	933 N MAYFAIR RD
Second Line	:	SUITE 303
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-3432
Country	:	US
Telephone Number	:	414-456-9929
Fax Number	:	414-456-9994

Authorized Official
Title or Position	:	CO DIRECTOR PSYCHOTHERAPIST
Name	:	HELEN M PONEC
Credential	:	LCSW MSW
Telephone Number	:	414-456-9929

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	12/05/2008

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Directions to “STILLWATER COUNSELING CENTER ” Practice Location

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