Provider Demographics
NPI:1205436292
Name:RIVER VALLEY RENEWAL COUNSELING AND WELLNESS CENTER
Entity type:Organization
Organization Name:RIVER VALLEY RENEWAL COUNSELING AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BREAULT
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:715-483-7300
Mailing Address - Street 1:809 US HIGHWAY 8
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-8335
Mailing Address - Country:US
Mailing Address - Phone:715-483-7300
Mailing Address - Fax:715-483-7301
Practice Address - Street 1:809 US HIGHWAY 8
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-8335
Practice Address - Country:US
Practice Address - Phone:715-483-7300
Practice Address - Fax:715-483-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1902207012Medicaid