Provider Demographics
NPI:1215321633
Name:AFFILIATED COUNSELING CENTER, LLC
Entity type:Organization
Organization Name:AFFILIATED COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PAYROLL
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:920-887-8751
Mailing Address - Street 1:108 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2110
Mailing Address - Country:US
Mailing Address - Phone:920-887-8751
Mailing Address - Fax:920-887-3977
Practice Address - Street 1:108 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2110
Practice Address - Country:US
Practice Address - Phone:920-887-8751
Practice Address - Fax:920-887-3977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1630-57251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health