Provider Demographics
NPI:1659579928
Name:FOUNDATIONS COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:FOUNDATIONS COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE CO-DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:COLLEEN
Authorized Official - Last Name:KELLY-MARTINA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:608-424-9100
Mailing Address - Street 1:619 RIVER ST STE F
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53508-9117
Mailing Address - Country:US
Mailing Address - Phone:608-424-9100
Mailing Address - Fax:608-424-9099
Practice Address - Street 1:619 RIVER ST STE F
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53508-9117
Practice Address - Country:US
Practice Address - Phone:608-424-9100
Practice Address - Fax:608-424-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2508101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42234600Medicaid