Provider Demographics
NPI:1841374691
Name:CAMBRIDGE COUNSELING CLINIC INC
Entity type:Organization
Organization Name:CAMBRIDGE COUNSELING CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:C
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:608-423-4700
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:WI
Mailing Address - Zip Code:53523-0548
Mailing Address - Country:US
Mailing Address - Phone:608-423-4700
Mailing Address - Fax:608-423-7751
Practice Address - Street 1:120 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:WI
Practice Address - Zip Code:53523-0548
Practice Address - Country:US
Practice Address - Phone:608-423-4700
Practice Address - Fax:608-423-7751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1122261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42142900Medicaid
Y30531Medicare UPIN
WI42142900Medicaid