Provider Demographics
NPI:1992858179
Name:APPLETON PSYCHIATRIC & COUNSELING CENTER
Entity Type:Organization
Organization Name:APPLETON PSYCHIATRIC & COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOSSENS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:920-882-6610
Mailing Address - Street 1:477 S NICOLET RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-8270
Mailing Address - Country:US
Mailing Address - Phone:920-882-6610
Mailing Address - Fax:920-882-6611
Practice Address - Street 1:477 S NICOLET RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-8270
Practice Address - Country:US
Practice Address - Phone:920-882-6610
Practice Address - Fax:920-882-6611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI802 1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39625900Medicaid