Provider Demographics
NPI:1265450753
Name:TRIVIUM LLC
Entity Type:Organization
Organization Name:TRIVIUM LLC
Other - Org Name:CROSSROADS COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:F
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MSSW, LCSW, LMFT
Authorized Official - Phone:608-755-5260
Mailing Address - Street 1:17 S. RIVER ST
Mailing Address - Street 2:SUITE 254
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-3863
Mailing Address - Country:US
Mailing Address - Phone:608-755-5260
Mailing Address - Fax:608-755-5267
Practice Address - Street 1:17 S. RIVER ST.
Practice Address - Street 2:SUITE 254
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3863
Practice Address - Country:US
Practice Address - Phone:608-755-5260
Practice Address - Fax:608-755-5267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
WI1265261QM0801X, 261QM0855X
WI2868261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42105900Medicaid
WI84310Medicare ID - Type Unspecified