Provider First Line Business Practice Location Address:
602 WALDOCH DR
Provider Second Line Business Practice Location Address:
SUITE 100/NORTH PARK CLINICAL COUNSELING
Provider Business Practice Location Address City Name:
APPLETON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54913-8445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-560-5531
Provider Business Practice Location Address Fax Number:
920-560-5533
Provider Enumeration Date:
09/26/2006