Provider Demographics
NPI:1124093547
Name:COUNSELING ASSOCIATES OF DOOR COUNTY, LLC
Entity type:Organization
Organization Name:COUNSELING ASSOCIATES OF DOOR COUNTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:NICK
Authorized Official - Suffix:
Authorized Official - Credentials:MSE, LCSW
Authorized Official - Phone:920-743-9554
Mailing Address - Street 1:PO BOX 873
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-0873
Mailing Address - Country:US
Mailing Address - Phone:920-559-7482
Mailing Address - Fax:920-743-1591
Practice Address - Street 1:620 N 12TH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1249
Practice Address - Country:US
Practice Address - Phone:920-743-9554
Practice Address - Fax:920-743-1591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2924-125101Y00000X
261Q00000X
WI1250101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42176400Medicaid
WI000088867Medicare Oscar/Certification
WI000088867Medicare PIN