Provider Demographics
NPI:1013181502
Name:ADVANCE THERAPY MENTAL HEALTH AND RECOVERY SERVICES LLC
Entity Type:Organization
Organization Name:ADVANCE THERAPY MENTAL HEALTH AND RECOVERY SERVICES LLC
Other - Org Name:ADVANCE THERAPY MENTAL HEALTH AND RECOVERY SERVICES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:COAD
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:712-277-3200
Mailing Address - Street 1:705 DOUGLAS ST STE 325
Mailing Address - Street 2:BENSON BLDG
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1016
Mailing Address - Country:US
Mailing Address - Phone:712-277-3200
Mailing Address - Fax:712-277-3208
Practice Address - Street 1:705 DOUGLAS ST STE 325
Practice Address - Street 2:BENSON BLDG
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1016
Practice Address - Country:US
Practice Address - Phone:712-277-3200
Practice Address - Fax:712-277-3208
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCE THERAPY MENTAL HEALTH AND RECOVERY SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA012841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2190223Medicaid
IA1041CO7004OtherCLINICAL SOCIAL WORK
80OtherCMS CODE
IA2190223Medicaid
IA2190223Medicaid