Provider Demographics
NPI:1437323680
Name:IMPACT COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:IMPACT COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:715-634-0607
Mailing Address - Street 1:15655 COUNTY ROAD B
Mailing Address - Street 2:PO BOX 13251
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-3251
Mailing Address - Country:US
Mailing Address - Phone:715-634-0607
Mailing Address - Fax:
Practice Address - Street 1:15655 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-3251
Practice Address - Country:US
Practice Address - Phone:715-634-0607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43005300261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43005300Medicaid