| NPI | 1871865253 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TANYA MAULDIN Provider Enrollment Manager 414-225-1611 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: MI 6801017866) |
| 101YM0800X Counselor, Mental Health | |
| Enumeration Date | 2012-02-01 |
| Last Update Date | 2025-09-08 |