Healthcare Provider Details

I. General information

NPI: 1669602488
Provider Name (Legal Business Name): AADVANTAGE BEHAVIORAL HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E PINE ST
LAKE MILLS WI
53551-1103
US

IV. Provider business mailing address

N6658 WOODFIELD LN
LAKE MILLS WI
53551-9740
US

V. Phone/Fax

Practice location:
  • Phone: 608-843-4555
  • Fax:
Mailing address:
  • Phone: 608-843-4555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6647-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number2498
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number6647-123
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number6647-123
License Number StateWI

VIII. Authorized Official

Name: MAUREEN GALE BUSS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 608-843-4555