Provider Demographics
NPI:1376250795
Name:NEW DEPTH COUNSELING & WELLNESS SERVICES, LLC
Entity Type:Organization
Organization Name:NEW DEPTH COUNSELING & WELLNESS SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:920-301-3546
Mailing Address - Street 1:N6921 WOODSIDE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-1681
Mailing Address - Country:US
Mailing Address - Phone:920-980-0316
Mailing Address - Fax:
Practice Address - Street 1:1345 W MASON ST STE 102
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2049
Practice Address - Country:US
Practice Address - Phone:920-301-3546
Practice Address - Fax:920-301-3400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-04
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)