Healthcare Provider Details

I. General information

NPI: 1285237958
Provider Name (Legal Business Name): DIFFERENT HORIZONS BEHAVIORAL HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 N 30TH ST
MILWAUKEE WI
53208-2420
US

IV. Provider business mailing address

1337 N 30TH ST
MILWAUKEE WI
53208-2420
US

V. Phone/Fax

Practice location:
  • Phone: 414-394-5517
  • Fax:
Mailing address:
  • Phone: 414-394-5517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. LATIKA NICOLE WASHINGTON
Title or Position: EXERCUTIVE DIRECTOR
Credential: CSAC, LPC-IT, ICS
Phone: 414-394-5517