MEDICARE: ANDERS DEVELOPMENTAL & TRANSITION HOME LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1134764103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDERS DEVELOPMENTAL & TRANSITION HOME LLC

Provider Business Mailing Address
First Line	:	PO BOX 342563
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53234-2563
Country	:	US
Telephone Number	:	414-509-7517
Fax Number	:	414-255-3532

Provider Business Practice Location Address
First Line	:	3359 N 25TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53206-1237
Country	:	US
Telephone Number	:	414-509-7517
Fax Number	:

Authorized Official
Title or Position	:	OFFICER
Name	:	SUSIE K ANDERS
Credential	:
Telephone Number	:	414-899-9897

Provider Enumeration Date	:	11/13/2019
Last Update Date	:	11/13/2019

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