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General NPI Number Information
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NPI Number | 1871434415
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Entity Type | Organization
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Legal Business Name | TIARAED WARRIOR LLC
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Dates
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Enumeration Date | 04/06/2026
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Last Update Date | 04/06/2026
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Provider Practice Location Address
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Address Line | 2800 E ENTERPRISE AVE STE 333
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City | APPLETON
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State | WI
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Zip | 54913-7889
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Country | US
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Telephone | 920-212-8927
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Fax |
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Provider Business Mailing Address
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Address Line | 915 OSHKOSH ST
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City | NEW LONDON
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State | WI
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Zip | 54961-1633
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Country | US
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Telephone | 262-325-7424
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DEBRA L VANDENBOOM
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Credential | MAPCC LPC
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Telephone | 262-325-7424
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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