Provider Demographics
NPI:1952653271
Name:PROFESSIONAL FAMILY RESOURCES & ASSOCIATES LLC
Entity Type:Organization
Organization Name:PROFESSIONAL FAMILY RESOURCES & ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLO PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:SELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA LMFT
Authorized Official - Phone:920-434-7457
Mailing Address - Street 1:2300 LINEVILLE ROAD STE 201
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313
Mailing Address - Country:US
Mailing Address - Phone:920-434-7457
Mailing Address - Fax:920-434-7460
Practice Address - Street 1:2300 LINEVILLE RD STE 200
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-8859
Practice Address - Country:US
Practice Address - Phone:920-434-7457
Practice Address - Fax:920-434-7460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI610-124104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39737600Medicaid