Basic Information
Provider Information | |||||||||
NPI: | 1467503193 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MILWAUKEE HEALTH SERVICES SYSTEM, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | APPLETON COMPREHENSIVE TREATMENT CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6183 PASEO DEL NORTE STE 200 | ||||||||
Address2: |   | ||||||||
City: | CARLSBAD | ||||||||
State: | CA | ||||||||
PostalCode: | 920111155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8552592288 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3301 N. BALLARD ROAD | ||||||||
Address2: | STE. B | ||||||||
City: | APPLETON | ||||||||
State: | WI | ||||||||
PostalCode: | 549118928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9207334443 | ||||||||
FaxNumber: | 9207334796 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2007 | ||||||||
LastUpdateDate: | 07/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SANDERSON | ||||||||
AuthorizedOfficialFirstName: | KIM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT, CTC DIVISION | ||||||||
AuthorizedOfficialTelephone: | 8552592288 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ACADIA HEALTHCARE COMPANY, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   | WI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 261QM2800X |   | WI | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.