Provider Demographics
NPI:1023640695
Name:DRIFTLESS COUNSELING LLC
Entity type:Organization
Organization Name:DRIFTLESS COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:608-606-6789
Mailing Address - Street 1:247 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-1815
Mailing Address - Country:US
Mailing Address - Phone:608-606-6789
Mailing Address - Fax:
Practice Address - Street 1:118 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-1613
Practice Address - Country:US
Practice Address - Phone:608-606-6789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Multi-Specialty
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1285029280Medicaid
WI1316486731Medicaid