1619675568 NPI number — BALANCED RECOVERY COUNSELING AND CONSULTATION LLC

Table of content: (NPI 1619675568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619675568 NPI number — BALANCED RECOVERY COUNSELING AND CONSULTATION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALANCED RECOVERY COUNSELING AND CONSULTATION LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1619675568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2809 E HAMILTON AVE # 4029
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAU CLAIRE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54701-6863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
534-429-1630
Provider Business Mailing Address Fax Number:
855-674-1884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
532 E SAINT JOSEPH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54301-2246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
534-429-1630
Provider Business Practice Location Address Fax Number:
855-674-1884
Provider Enumeration Date:
02/20/2023

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
MORGAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/CLINICAL SOCIAL WORKER
Authorized Official Telephone Number:
534-429-1630

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1538400445 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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