Provider Demographics
NPI:1366004384
Name:PINE COUNSELING INC.
Entity Type:Organization
Organization Name:PINE COUNSELING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ELIJAH
Authorized Official - Middle Name:LAKE
Authorized Official - Last Name:KRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:SAC-IT
Authorized Official - Phone:920-285-0453
Mailing Address - Street 1:204 S ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-2170
Mailing Address - Country:US
Mailing Address - Phone:931-982-4832
Mailing Address - Fax:608-383-1480
Practice Address - Street 1:204 S ORANGE ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-2170
Practice Address - Country:US
Practice Address - Phone:931-982-4832
Practice Address - Fax:608-383-1480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-29
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1184006652Medicaid