Provider Demographics
NPI:1811193675
Name:M D THERAPY LLC
Entity Type:Organization
Organization Name:M D THERAPY LLC
Other - Org Name:DIRECTORS OF CONTINUATION SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:414-264-6155
Mailing Address - Street 1:3118 N TEUTONIA AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-2264
Mailing Address - Country:US
Mailing Address - Phone:414-264-6155
Mailing Address - Fax:414-264-8288
Practice Address - Street 1:3118 N TEUTONIA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-2264
Practice Address - Country:US
Practice Address - Phone:414-264-6155
Practice Address - Fax:414-264-8288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2225101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIHFS 61.91OtherMENTAL HEALTH-OUTPATIENT
WIHFS 75.13OtherCSAS-OUTPATIENT TREATMENT