Healthcare Provider Details

I. General information

NPI: 1497171938
Provider Name (Legal Business Name): MAPLEGROVE TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 04/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 S 97TH ST
WEST ALLIS WI
53214-4133
US

IV. Provider business mailing address

1455 S 97TH ST
WEST ALLIS WI
53214-4133
US

V. Phone/Fax

Practice location:
  • Phone: 262-510-4447
  • Fax:
Mailing address:
  • Phone: 262-510-4447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3026
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number128973
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateWI

VIII. Authorized Official

Name: TIMOTHY KABARA
Title or Position: CENTER DIRECTOR
Credential: LMHP
Phone: 262-510-4447