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General NPI Number Information
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NPI Number | 1285902015
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Entity Type | Organization
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Legal Business Name | ADVOCATES FOR HEALTHY TRANSITIONAL LIVING, LLC
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Dates
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Enumeration Date | 12/07/2011
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Last Update Date | 12/07/2011
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Provider Practice Location Address
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Address Line | 3021 HOLMGREN WAY SUITE 203
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City | GREEN BAY
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State | WI
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Zip | 54304-6302
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Country | US
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Telephone | 920-634-6162
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Fax | 920-339-9374
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Provider Business Mailing Address
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Address Line | 3021 HOLMGREN WAY SUITE 203
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City | GREEN BAY
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State | WI
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Zip | 54304-6302
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Country | US
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Telephone | 920-634-6162
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Fax | 920-339-9374
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. DANIEL ROBERT HOLSTEAD
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Credential | LCSW
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Telephone | 920-634-6162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253J00000X
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Taxonomy Name | Foster Care Agency
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License Number | 8038182
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License Number State | WI
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