Provider Demographics
NPI:1689149700
Name:BIRT SUPPORTIVE SERVICES LLC
Entity Type:Organization
Organization Name:BIRT SUPPORTIVE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, MBA
Authorized Official - Phone:414-522-6800
Mailing Address - Street 1:4868 N 89TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-4106
Mailing Address - Country:US
Mailing Address - Phone:414-522-6800
Mailing Address - Fax:414-240-8497
Practice Address - Street 1:6815 W CAPITOL DR STE 105
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:414-522-6800
Practice Address - Fax:414-240-8497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-04
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)