MEDICARE: GLEN HAVEN COUNSELING CLINIC

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	251S00000X	Community/Behavioral Health Agency	1384	WI

General Provider Information

NPI Number	:	1285844480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLEN HAVEN COUNSELING CLINIC

Provider Business Mailing Address
First Line	:	6270 N PORT WASHINGTON RD
Second Line	:	SUITE 201
City	:	GLENDALE
State	:	WI
Zip	:	53217-4311
Country	:	US
Telephone Number	:	414-962-2284
Fax Number	:

Provider Business Practice Location Address
First Line	:	6270 N PORT WASHINGTON RD
Second Line	:	SUITE 201
City	:	GLENDALE
State	:	WI
Zip	:	53217-4311
Country	:	US
Telephone Number	:	414-962-2284
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JERROLD BERNARD ROUSSEAU
Credential	:	MSSW, LCSW
Telephone Number	:	414-962-2284

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	08/22/2020

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