Provider Demographics
NPI:1417160953
Name:RIVERSIDE COUNSELING CLINIC, LLC
Entity Type:Organization
Organization Name:RIVERSIDE COUNSELING CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILLOUGHBY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:715-833-7600
Mailing Address - Street 1:130 S BARSTOW ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3691
Mailing Address - Country:US
Mailing Address - Phone:715-833-7600
Mailing Address - Fax:715-833-7116
Practice Address - Street 1:130 S BARSTOW ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3691
Practice Address - Country:US
Practice Address - Phone:715-833-7600
Practice Address - Fax:715-833-7116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2375-057103TC0700X
WI6585-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty