Provider Demographics
NPI:1255790630
Name:CEDAR LAKE COUNSELING, SC
Entity type:Organization
Organization Name:CEDAR LAKE COUNSELING, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:SOLVITA
Authorized Official - Middle Name:
Authorized Official - Last Name:BORG
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:262-244-6178
Mailing Address - Street 1:1035 W GLEN OAKS LN STE 110
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3392
Mailing Address - Country:US
Mailing Address - Phone:262-244-6178
Mailing Address - Fax:262-299-3040
Practice Address - Street 1:1035 W GLEN OAKS LN STE 110
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3392
Practice Address - Country:US
Practice Address - Phone:262-244-6178
Practice Address - Fax:262-299-3040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty