Basic Information
| Provider Information | |||||||||
| NPI: | 1548542236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLE | ||||||||
| FirstName: | MEGHAN | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC, CSAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCDONALD | ||||||||
| OtherFirstName: | MEGHAN | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC, CSAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1020 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549356138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209239054 | ||||||||
| FaxNumber: | 9203229193 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549356138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209239054 | ||||||||
| FaxNumber: | 9203229193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2011 | ||||||||
| LastUpdateDate: | 12/14/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 15578-132 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 4527-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.