MEDICARE: PINE COUNSELING INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	261QM0850X	Adult Mental Health Clinic/Center
3	261QM0855X	Adolescent and Children Mental Health Clinic/Center
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366004384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE COUNSELING INC.

Provider Business Mailing Address
First Line	:	204 S ORANGE ST
Second Line	:
City	:	RICHLAND CENTER
State	:	WI
Zip	:	53581-2170
Country	:	US
Telephone Number	:	931-982-4832
Fax Number	:	608-383-1480

Provider Business Practice Location Address
First Line	:	204 S ORANGE ST
Second Line	:
City	:	RICHLAND CENTER
State	:	WI
Zip	:	53581-2170
Country	:	US
Telephone Number	:	931-982-4832
Fax Number	:	608-383-1480

Authorized Official
Title or Position	:	BOARD MEMBER
Name	:	ELIJAH LAKE KRAMER
Credential	:	SAC-IT
Telephone Number	:	920-285-0453

Provider Enumeration Date	:	06/29/2019
Last Update Date	:	12/08/2019

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Directions to “PINE COUNSELING INC. ” Practice Location

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