MEDICARE: FAITH FACTORY LLC

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1265151906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAITH FACTORY LLC

Provider Business Mailing Address
First Line	:	790 N MILWAUKEE ST STE 312
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-3724
Country	:	US
Telephone Number	:	262-706-5868
Fax Number	:

Provider Business Practice Location Address
First Line	:	790 N MILWAUKEE ST STE 312
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-3724
Country	:	US
Telephone Number	:	262-706-5868
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LISA ROTH
Credential	:	LPC
Telephone Number	:	262-706-5868

Provider Enumeration Date	:	08/25/2022
Last Update Date	:	08/25/2022

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Directions to “FAITH FACTORY LLC ” Practice Location

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