Provider Demographics
NPI:1568659365
Name:COUNSELING CONNECTION OF MEDFORD LLC
Entity Type:Organization
Organization Name:COUNSELING CONNECTION OF MEDFORD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPC AND SAC
Authorized Official - Phone:715-748-4312
Mailing Address - Street 1:123 W STATE ST
Mailing Address - Street 2:SUITE #4
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1772
Mailing Address - Country:US
Mailing Address - Phone:715-748-4312
Mailing Address - Fax:715-748-4407
Practice Address - Street 1:123 W STATE ST
Practice Address - Street 2:SUITE #4
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1772
Practice Address - Country:US
Practice Address - Phone:715-748-4312
Practice Address - Fax:715-748-4407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3054-125261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43576100Medicaid