=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639790256
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRAILWAYS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2020
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 E MAIN ST STE 4
-----------------------------------------------------
City | WAUNAKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53597-1196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-886-9023
-----------------------------------------------------
Fax | 608-200-2417
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 454
-----------------------------------------------------
City | WAUNAKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53597-0454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-886-9023
-----------------------------------------------------
Fax | 608-200-2417
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER/DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | ANGIE GROGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-301-5376
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------