Provider Demographics
NPI:1093869588
Name:INNOVATIVE COUNSELING INC
Entity Type:Organization
Organization Name:INNOVATIVE COUNSELING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW ACSW
Authorized Official - Phone:920-497-6161
Mailing Address - Street 1:1499 6TH ST
Mailing Address - Street 2:INNOVATIVE COUNSELING INC
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-2252
Mailing Address - Country:US
Mailing Address - Phone:920-497-6161
Mailing Address - Fax:920-498-0476
Practice Address - Street 1:1499 6TH ST
Practice Address - Street 2:INNOVATIVE COUNSELING INC
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-2252
Practice Address - Country:US
Practice Address - Phone:920-497-6161
Practice Address - Fax:920-498-0476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2283251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42207500Medicaid
WIWI1391Medicaid