Provider Demographics
NPI:1306095823
Name:FAMILY COUNSELING CENTER, LLC
Entity type:Organization
Organization Name:FAMILY COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ZIEMER
Authorized Official - Last Name:NERVIG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:414-258-5523
Mailing Address - Street 1:8112 W BLUEMOUND RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3356
Mailing Address - Country:US
Mailing Address - Phone:414-258-5523
Mailing Address - Fax:414-431-1071
Practice Address - Street 1:8112 W BLUEMOUND RD
Practice Address - Street 2:SUITE 106
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-3356
Practice Address - Country:US
Practice Address - Phone:414-258-5523
Practice Address - Fax:414-431-1071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI475-123251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42193700Medicaid