Provider Demographics
NPI:1609129410
Name:TELLURIAN, INC.
Entity Type:Organization
Organization Name:TELLURIAN, INC.
Other - Org Name:TELLURIAN UCAN INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:QUALITY ASSURANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-663-2120
Mailing Address - Street 1:300 FEMRITE DR
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-3716
Mailing Address - Country:US
Mailing Address - Phone:608-222-7311
Mailing Address - Fax:608-463-1440
Practice Address - Street 1:300 FEMRITE DR
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-3716
Practice Address - Country:US
Practice Address - Phone:608-222-7311
Practice Address - Fax:608-463-1440
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TELLURIAN, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-17
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness