Healthcare Provider Details

I. General information

NPI: 1831315191
Provider Name (Legal Business Name): ALLIED MENTAL HEALTH SPECIALTY GROUP SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 05/09/2020
Certification Date: 05/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1334 HOSFORD ST STE B
HUDSON WI
54016-9230
US

IV. Provider business mailing address

1334 HOSFORD ST STE B
HUDSON WI
54016-9230
US

V. Phone/Fax

Practice location:
  • Phone: 715-808-0795
  • Fax: 715-808-0361
Mailing address:
  • Phone: 715-808-0795
  • Fax: 715-808-0361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1436-057
License Number StateWI

VIII. Authorized Official

Name: BRADLEY G NEVINS
Title or Position: OWNER
Credential:
Phone: 715-808-0795