Basic Information
| Provider Information | |||||||||
| NPI: | 1689981912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YELLOW THUNDER | ||||||||
| FirstName: | ALETA | ||||||||
| MiddleName: | AVIS | ||||||||
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| Credential: | BA, SACIT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 247 | ||||||||
| Address2: | |||||||||
| City: | WITTENBERG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544990247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152536064 | ||||||||
| FaxNumber: | 7152532897 | ||||||||
| Practice Location | |||||||||
| Address1: | N7240 US HIGHWAY 45 | ||||||||
| Address2: | |||||||||
| City: | WITTENBERG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544998567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152536064 | ||||||||
| FaxNumber: | 7152532897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2010 | ||||||||
| LastUpdateDate: | 09/08/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 13680-130 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.