Provider Demographics
NPI:1427775840
Name:WISCONSIN ANXIETY AND DEPRESSION CLINIC, LLC.
Entity type:Organization
Organization Name:WISCONSIN ANXIETY AND DEPRESSION CLINIC, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:262-682-3147
Mailing Address - Street 1:200 W SUMMIT AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:WALES
Mailing Address - State:WI
Mailing Address - Zip Code:53183-9431
Mailing Address - Country:US
Mailing Address - Phone:262-682-3147
Mailing Address - Fax:
Practice Address - Street 1:200 W SUMMIT AVE STE 260
Practice Address - Street 2:
Practice Address - City:WALES
Practice Address - State:WI
Practice Address - Zip Code:53183-9431
Practice Address - Country:US
Practice Address - Phone:262-682-3147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health