Provider Demographics
NPI:1104026665
Name:CHRISTIAN COMMUNITY RESOURCES, LLC
Entity Type:Organization
Organization Name:CHRISTIAN COMMUNITY RESOURCES, LLC
Other - Org Name:FREEDOM COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LACE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:715-838-8898
Mailing Address - Street 1:PO BOX 1426
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1426
Mailing Address - Country:US
Mailing Address - Phone:715-552-7350
Mailing Address - Fax:
Practice Address - Street 1:2141 ALTOONA AVE
Practice Address - Street 2:SUITE C
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3429
Practice Address - Country:US
Practice Address - Phone:715-552-7350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33333103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39365600Medicaid