Basic Information
| Provider Information | |||||||||
| NPI: | 1154338374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAUERS | ||||||||
| FirstName: | MONTINE | ||||||||
| MiddleName: | RENE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NCC, LPC, SAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 16024 WEST SANTA ROSA BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627515150 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2000 E LAYTON AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT FRANCIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532356053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147446589 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 3185 | WI | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 3185-125 | WI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 3185 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 40942200 | 05 | WI | MEDICAID |