Provider Demographics
NPI:1871953216
Name:N/A
Entity type:Organization
Organization Name:N/A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELING
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:608-436-1727
Mailing Address - Street 1:1203 SAINT LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-5067
Mailing Address - Country:US
Mailing Address - Phone:608-436-1727
Mailing Address - Fax:
Practice Address - Street 1:1203 SAINT LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-5067
Practice Address - Country:US
Practice Address - Phone:608-436-1727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-27
Last Update Date:2016-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2817226251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health