Provider Demographics
NPI:1235302480
Name:TELLURIAN, INC.
Entity Type:Organization
Organization Name:TELLURIAN, INC.
Other - Org Name:TELLURIAN UCAN INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:QUALITY ASSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:E
Authorized Official - Last Name:CROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:608-663-2120
Mailing Address - Street 1:300 FEMRITE DR
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-3716
Mailing Address - Country:US
Mailing Address - Phone:608-222-7311
Mailing Address - Fax:608-222-5904
Practice Address - Street 1:300 FEMRITE DR
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-3716
Practice Address - Country:US
Practice Address - Phone:608-222-7311
Practice Address - Fax:608-222-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI774251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39394400Medicaid