Healthcare Provider Details

I. General information

NPI: 1750034963
Provider Name (Legal Business Name): FOUNDATIONS OF COMMUNITY LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 ERIE AVE
SHEBOYGAN WI
53081-3384
US

IV. Provider business mailing address

618 ROOSEVELT RD
KOHLER WI
53044-1618
US

V. Phone/Fax

Practice location:
  • Phone: 920-912-7749
  • Fax:
Mailing address:
  • Phone: 920-912-7749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. TARA P TAYLOR
Title or Position: OWNER
Credential: LPC
Phone: 920-912-7749