Provider Demographics
NPI:1760890636
Name:A-VIAN PSYCHOTHERAPY
Entity Type:Organization
Organization Name:A-VIAN PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-213-9533
Mailing Address - Street 1:1840 N FARWELL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-1792
Mailing Address - Country:US
Mailing Address - Phone:414-231-9533
Mailing Address - Fax:
Practice Address - Street 1:1840 N FARWELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-1792
Practice Address - Country:US
Practice Address - Phone:414-231-9533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4953-125261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100027177Medicaid