Provider Demographics
NPI:1225439326
Name:EXPRESSIVE THERAPIES LLC
Entity Type:Organization
Organization Name:EXPRESSIVE THERAPIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRIMARY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-284-0891
Mailing Address - Street 1:510 E WISCONSIN AVE
Mailing Address - Street 2:A
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-4865
Mailing Address - Country:US
Mailing Address - Phone:920-284-0891
Mailing Address - Fax:800-791-3601
Practice Address - Street 1:510 E WISCONSIN AVE
Practice Address - Street 2:A
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-4865
Practice Address - Country:US
Practice Address - Phone:920-284-0891
Practice Address - Fax:800-791-3601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7854-123251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health