Basic Information
| Provider Information | |||||||||
| NPI: | 1134355308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CEDAR CREEK COUNSELING, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 W GLEN OAKS LN | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530923392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622400299 | ||||||||
| FaxNumber: | 2622400308 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 W GLEN OAKS LN | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530923392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622400299 | ||||||||
| FaxNumber: | 2622400308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 09/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | BLOEMER | ||||||||
| AuthorizedOfficialFirstName: | BYRON | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2622400299 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 057-2140 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.