Provider Demographics
NPI:1386189363
Name:ANCHOR BAY COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:ANCHOR BAY COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:715-939-1393
Mailing Address - Street 1:PO BOX 574
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-0574
Mailing Address - Country:US
Mailing Address - Phone:715-939-1393
Mailing Address - Fax:
Practice Address - Street 1:329 S RIVER ST # 301
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-9726
Practice Address - Country:US
Practice Address - Phone:715-939-1393
Practice Address - Fax:715-939-1394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3433-125251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40980600Medicaid