Provider Demographics
NPI:1427208784
Name:BRIDGEPORT COUNSELING
Entity Type:Organization
Organization Name:BRIDGEPORT COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:PANULA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:715-395-7825
Mailing Address - Street 1:2231 CATLIN AVE
Mailing Address - Street 2:ROOM #310
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5137
Mailing Address - Country:US
Mailing Address - Phone:715-395-7825
Mailing Address - Fax:715-395-7826
Practice Address - Street 1:2231 CATLIN AVE
Practice Address - Street 2:ROOM #310
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5137
Practice Address - Country:US
Practice Address - Phone:715-395-7825
Practice Address - Fax:715-395-7826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2837-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty