Provider Demographics
NPI:1811580574
Name:BRAVE SPACES COUNSELING AND WELLNESS, LLC
Entity Type:Organization
Organization Name:BRAVE SPACES COUNSELING AND WELLNESS, LLC
Other - Org Name:INFINITY TRAINING & CONSULTING
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLIREN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:608-386-5495
Mailing Address - Street 1:605 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4458
Mailing Address - Country:US
Mailing Address - Phone:608-386-5495
Mailing Address - Fax:
Practice Address - Street 1:605 4TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4458
Practice Address - Country:US
Practice Address - Phone:608-386-5495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-14
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1033777800Medicaid
WI100007945Medicaid
WI100031418Medicaid