Provider Demographics
NPI:1710153051
Name:LIBERTY COUNSELING
Entity Type:Organization
Organization Name:LIBERTY COUNSELING
Other - Org Name:N/A
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LMFT
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:GROVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-290-0107
Mailing Address - Street 1:141 W HURON ST
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1587
Mailing Address - Country:US
Mailing Address - Phone:920-290-0107
Mailing Address - Fax:
Practice Address - Street 1:141 W HURON ST
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1587
Practice Address - Country:US
Practice Address - Phone:920-290-0107
Practice Address - Fax:
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
WI652-124251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42244600Medicaid