Provider Demographics
NPI:1841344116
Name:WINONA COUNSELING CLINIC, INC.
Entity type:Organization
Organization Name:WINONA COUNSELING CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR / OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPCC, LPC, LADC
Authorized Official - Phone:507-454-3900
Mailing Address - Street 1:111 RIVERFRONT
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3456
Mailing Address - Country:US
Mailing Address - Phone:507-454-3900
Mailing Address - Fax:507-452-7459
Practice Address - Street 1:111 RIVERFRONT
Practice Address - Street 2:SUITE 210
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3456
Practice Address - Country:US
Practice Address - Phone:507-454-3900
Practice Address - Fax:507-452-7459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8306881CDT251S00000X
WI2009251S00000X
MN1028139-1-MHC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN38266WIOtherBLUE CROSS BLUE SHIELD
MN128661OtherUCARE
MN9166WIOtherBLUE CROSS BLUE SHIELD CD
MN326930OtherVALUE OPTIONS
MN800000244Medicare ID - Type Unspecified