Provider Demographics
NPI:1518346261
Name:HEALTHY MINDS OF THE FOX VALLEY LLC
Entity Type:Organization
Organization Name:HEALTHY MINDS OF THE FOX VALLEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HIETPAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:715-937-8819
Mailing Address - Street 1:6188 CLARKS RD
Mailing Address - Street 2:
Mailing Address - City:WINNECONNE
Mailing Address - State:WI
Mailing Address - Zip Code:54986-9760
Mailing Address - Country:US
Mailing Address - Phone:908-551-0013
Mailing Address - Fax:
Practice Address - Street 1:1045 N LYNNDALE DR
Practice Address - Street 2:STE 1C
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3048
Practice Address - Country:US
Practice Address - Phone:902-551-0013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI72200-1519103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty