1811193675 NPI number — M D THERAPY LLC

Table of content: (NPI 1811193675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811193675 NPI number — M D THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M D THERAPY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DIRECTORS OF CONTINUATION SERVICES
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811193675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3118 N TEUTONIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53206-2264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-264-6155
Provider Business Mailing Address Fax Number:
414-264-8288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3118 N TEUTONIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53206-2264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-264-6155
Provider Business Practice Location Address Fax Number:
414-264-8288
Provider Enumeration Date:
06/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DALE
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
414-264-6155

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  2225 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: 2225 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HFS 61.91 . This is a "MENTAL HEALTH-OUTPATIENT" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: HFS 75.13 . This is a "CSAS-OUTPATIENT TREATMENT" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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