Provider Demographics
NPI:1497171938
Name:MAPLEGROVE TREATMENT CENTER
Entity Type:Organization
Organization Name:MAPLEGROVE TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CENTER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KABARA
Authorized Official - Suffix:
Authorized Official - Credentials:LMHP
Authorized Official - Phone:262-510-4447
Mailing Address - Street 1:1455 S 97TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4133
Mailing Address - Country:US
Mailing Address - Phone:262-510-4447
Mailing Address - Fax:
Practice Address - Street 1:1455 S 97TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4133
Practice Address - Country:US
Practice Address - Phone:262-510-4447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-07
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3026101YM0800X
103K00000X, 222Q00000X, 251C00000X
WI1289731041C0700X
WI253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty