Healthcare Provider Details

I. General information

NPI: 1174992895
Provider Name (Legal Business Name): MATT TALBOT RECOVERY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2613 W NORTH AVE
MILWAUKEE WI
53205-1056
US

IV. Provider business mailing address

2613 W NORTH AVE
MILWAUKEE WI
53205-1056
US

V. Phone/Fax

Practice location:
  • Phone: 414-342-5474
  • Fax: 414-342-5476
Mailing address:
  • Phone: 414-342-5474
  • Fax: 414-342-5476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANTONEO DESHAZOR
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 414-793-3896