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General NPI Number Information
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NPI Number | 1598215980
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Entity Type | Organization
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Legal Business Name | CROSSROADS COGNITIVE BEHAVIORAL SERVICES
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Dates
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Enumeration Date | 10/10/2016
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Last Update Date | 10/10/2016
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Provider Practice Location Address
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Address Line | 2454 W LISBON AVE
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City | MILWAUKEE
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State | WI
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Zip | 53205-1413
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Country | US
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Telephone | 414-562-6361
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Fax | 414-204-8689
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Provider Business Mailing Address
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Address Line | 2454 W LISBON AVE
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City | MILWAUKEE
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State | WI
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Zip | 53205-1413
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Country | US
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Telephone | 414-562-6361
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Fax | 414-204-8689
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. DERECK MCCLENDON
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Credential |
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Telephone | 414-562-6361
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | WI
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