1881716108 NPI number — CENTER FOR ANXIETY DISORDERS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881716108 NPI number — CENTER FOR ANXIETY DISORDERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR ANXIETY DISORDERS
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:
Provider Other Organization Name Type Code:
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:
1881716108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1124 W WISCONSIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCONOMOWOC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53066-2629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-567-9769
Provider Business Mailing Address Fax Number:
262-567-5560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
436 SUMMIT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCONOMOWOC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53066-3749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-719-3825
Provider Business Practice Location Address Fax Number:
262-567-5560
Provider Enumeration Date:
04/06/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RIEMANN
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
CHRISTOPHER
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
262-567-9769

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  1853 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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