Provider Demographics
NPI:1417795329
Name:TABLETOP RECOVERY LLC
Entity type:Organization
Organization Name:TABLETOP RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDDER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:715-222-7588
Mailing Address - Street 1:W3476 MORNINGSIDE RD
Mailing Address - Street 2:
Mailing Address - City:SARONA
Mailing Address - State:WI
Mailing Address - Zip Code:54870-9274
Mailing Address - Country:US
Mailing Address - Phone:715-222-7588
Mailing Address - Fax:
Practice Address - Street 1:111 ELM ST
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-1327
Practice Address - Country:US
Practice Address - Phone:715-222-7588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-16
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty