Provider Demographics
NPI:1164568879
Name:AFFILIATED COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:AFFILIATED COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCHWEFEL MASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:RN LCSW
Authorized Official - Phone:920-887-8751
Mailing Address - Street 1:108 N LINCOLN AVENUE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916
Mailing Address - Country:US
Mailing Address - Phone:920-887-8751
Mailing Address - Fax:920-887-3977
Practice Address - Street 1:108 N LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916
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:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42187100Medicaid