Provider Demographics
NPI:1689981912
Name:YELLOW THUNDER, ALETA AVIS (BA, SACIT)
Entity Type:Individual
Prefix:
First Name:ALETA
Middle Name:AVIS
Last Name:YELLOW THUNDER
Suffix:
Gender:F
Credentials:BA, SACIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:WITTENBERG
Mailing Address - State:WI
Mailing Address - Zip Code:54499-0247
Mailing Address - Country:US
Mailing Address - Phone:715-253-6064
Mailing Address - Fax:715-253-2897
Practice Address - Street 1:N7240 US HIGHWAY 45
Practice Address - Street 2:
Practice Address - City:WITTENBERG
Practice Address - State:WI
Practice Address - Zip Code:54499-8567
Practice Address - Country:US
Practice Address - Phone:715-253-6064
Practice Address - Fax:715-253-2897
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13680-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)