Provider Demographics
NPI:1508175118
Name:CITY TRANSFORMATION, LIMITED
Entity Type:Organization
Organization Name:CITY TRANSFORMATION, LIMITED
Other - Org Name:CITY TRANSFORMATION CLINIC NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:CLINICAL SUPERVISOR
Authorized Official - Phone:414-616-9744
Mailing Address - Street 1:6815 W CAPITOL DR STE 301
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2056
Mailing Address - Country:US
Mailing Address - Phone:414-616-9744
Mailing Address - Fax:414-616-9747
Practice Address - Street 1:6815 W CAPITOL DR STE 301
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2056
Practice Address - Country:US
Practice Address - Phone:414-616-9744
Practice Address - Fax:414-616-9747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2918101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI193400000XMedicaid