Healthcare Provider Details

I. General information

NPI: 1144400383
Provider Name (Legal Business Name): NORTHERN CROSSING BEHAVIORAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 07/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5303 W NORTH AVE
MILWAUKEE WI
53208
US

IV. Provider business mailing address

5303 W NORTH AVE
MILWAUKEE WI
53208-1021
US

V. Phone/Fax

Practice location:
  • Phone: 414-445-0997
  • Fax: 414-445-0989
Mailing address:
  • Phone: 414-445-0997
  • Fax: 414-445-0989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number2685
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number2685
License Number StateWI

VIII. Authorized Official

Name: AMBER RADULOVICH
Title or Position: BILLING MANAGER
Credential:
Phone: 414-445-0997