Provider Demographics
NPI:1528503497
Name:ADVANCED THERAPIES LLC
Entity type:Organization
Organization Name:ADVANCED THERAPIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:LAYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:262-506-4050
Mailing Address - Street 1:4402 S. 68TH ST.
Mailing Address - Street 2:STE104
Mailing Address - City:GREENFEILD
Mailing Address - State:WI
Mailing Address - Zip Code:53220
Mailing Address - Country:US
Mailing Address - Phone:262-506-4050
Mailing Address - Fax:
Practice Address - Street 1:4402 S 68TH ST
Practice Address - Street 2:STE104
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-3479
Practice Address - Country:US
Practice Address - Phone:262-506-4050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2417-123251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1295856219Medicaid
WI00284137Medicare PIN