Provider Demographics
NPI:1518328277
Name:INTEGRATED LIFE COUNSELING CENTER, LLC
Entity Type:Organization
Organization Name:INTEGRATED LIFE COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER, LCSW
Authorized Official - Prefix:
Authorized Official - First Name:HADWAT
Authorized Official - Middle Name:
Authorized Official - Last Name:SANKARI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:262-416-2922
Mailing Address - Street 1:265 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-4748
Mailing Address - Country:US
Mailing Address - Phone:262-416-2922
Mailing Address - Fax:
Practice Address - Street 1:215 N MAIN ST
Practice Address - Street 2:205
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3347
Practice Address - Country:US
Practice Address - Phone:262-416-2922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7824-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty