1205979168 NPI number — CLEARWATER COUNSELING AND PERSONAL GROWTH CENTER, INC.

Table of content: (NPI 1205979168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205979168 NPI number — CLEARWATER COUNSELING AND PERSONAL GROWTH CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEARWATER COUNSELING AND PERSONAL GROWTH CENTER, INC.
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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205979168
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4330 GOLF TER
Provider Second Line Business Mailing Address:
SUITE 213M
Provider Business Mailing Address City Name:
EAU CLAIRE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54701-4683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-832-4060
Provider Business Mailing Address Fax Number:
715-832-5914

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4330 GOLF TER
Provider Second Line Business Practice Location Address:
SUITE 213M
Provider Business Practice Location Address City Name:
EAU CLAIRE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54701-4683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-832-4060
Provider Business Practice Location Address Fax Number:
715-832-5914
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
O'CONNOR
Authorized Official First Name:
JANICE
Authorized Official Middle Name:
SUSAN
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
715-832-4060

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  1203 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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