Provider Demographics
NPI:1649574252
Name:MENTOR ABI
Entity Type:Organization
Organization Name:MENTOR ABI
Other - Org Name:NEURORESTORATIVE WISCONSIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-457-4729
Mailing Address - Street 1:10150 HIGHLAND MANOR DR STE 140
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-9712
Mailing Address - Country:US
Mailing Address - Phone:813-626-1444
Mailing Address - Fax:813-902-6719
Practice Address - Street 1:5310 BUENA PARK RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-2907
Practice Address - Country:US
Practice Address - Phone:262-534-4864
Practice Address - Fax:262-546-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0013091320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness