Provider Demographics
NPI:1548603657
Name:MINERVA COUNSELING CENTER
Entity Type:Organization
Organization Name:MINERVA COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-579-6205
Mailing Address - Street 1:493 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935
Mailing Address - Country:US
Mailing Address - Phone:715-579-6205
Mailing Address - Fax:
Practice Address - Street 1:493 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-5736
Practice Address - Country:US
Practice Address - Phone:715-579-6205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1612-226251S00000X
WI3883-125251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health