MEDICARE: TRIVIUM 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	261QM0855X	Adolescent and Children Mental Health Clinic/Center	2868	WI

General Provider Information

NPI Number	:	1427463066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIVIUM LLC

Provider Business Mailing Address
First Line	:	17 S RIVER ST
Second Line	:	SUITE 254
City	:	JANESVILLE
State	:	WI
Zip	:	53548-3860
Country	:	US
Telephone Number	:	608-755-5260
Fax Number	:	608-755-5267

Provider Business Practice Location Address
First Line	:	778 LOIS DR
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-1100
Country	:	US
Telephone Number	:	608-837-9112
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TIMOTHY PERRY
Credential	:	LCSW, LMFT
Telephone Number	:	608-755-5260

Provider Enumeration Date	:	06/23/2014
Last Update Date	:	06/23/2014

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Directions to “TRIVIUM LLC ” Practice Location

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