Provider Demographics
NPI:1285902015
Name:ADVOCATES FOR HEALTHY TRANSITIONAL LIVING, LLC
Entity type:Organization
Organization Name:ADVOCATES FOR HEALTHY TRANSITIONAL LIVING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HOLSTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:920-634-6162
Mailing Address - Street 1:3021 HOLMGREN WAY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-6302
Mailing Address - Country:US
Mailing Address - Phone:920-634-6162
Mailing Address - Fax:920-339-9374
Practice Address - Street 1:3021 HOLMGREN WAY
Practice Address - Street 2:SUITE 203
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-6302
Practice Address - Country:US
Practice Address - Phone:920-634-6162
Practice Address - Fax:920-339-9374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8038182253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39761600Medicaid