Provider Demographics
NPI:1740425941
Name:IMPACT COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:IMPACT COUNSELING SERVICES, LLC
Other - Org Name:ICS-FAMILY PARTNERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HINZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-369-6955
Mailing Address - Street 1:PO BOX 13251
Mailing Address - Street 2:15655 COUNTY ROAD B
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-3251
Mailing Address - Country:US
Mailing Address - Phone:715-634-0607
Mailing Address - Fax:
Practice Address - Street 1:17A W DAVENPORT ST
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-0742
Practice Address - Country:US
Practice Address - Phone:715-369-6955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42221700261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42221700Medicaid