Provider Demographics
NPI:1477205227
Name:NEURO ADVANTAGE REHABILITATION, LLC
Entity Type:Organization
Organization Name:NEURO ADVANTAGE REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:OLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:262-497-8099
Mailing Address - Street 1:7 CEDARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-2603
Mailing Address - Country:US
Mailing Address - Phone:262-497-8099
Mailing Address - Fax:
Practice Address - Street 1:13200 GLOBE DR STE 206
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1615
Practice Address - Country:US
Practice Address - Phone:262-497-8099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1881346609Medicaid