Provider Demographics
NPI:1629244983
Name:EASTLAKE COUNSELING AND CONSULTING II
Entity Type:Organization
Organization Name:EASTLAKE COUNSELING AND CONSULTING II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:414-272-0123
Mailing Address - Street 1:135 W WELLS ST
Mailing Address - Street 2:SUITE 226
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-1830
Mailing Address - Country:US
Mailing Address - Phone:414-272-0123
Mailing Address - Fax:414-272-3498
Practice Address - Street 1:135 W WELLS ST
Practice Address - Street 2:SUITE 226
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-1830
Practice Address - Country:US
Practice Address - Phone:414-272-0123
Practice Address - Fax:414-272-3498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty