Provider Demographics
NPI:1831315191
Name:ALLIED MENTAL HEALTH SPECIALTY GROUP SC
Entity Type:Organization
Organization Name:ALLIED MENTAL HEALTH SPECIALTY GROUP SC
Other - Org Name:ALLIED MENTAL HEALTH SPECIALTY GROUP SC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:NEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-808-0795
Mailing Address - Street 1:1334 HOSFORD ST STE B
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-9230
Mailing Address - Country:US
Mailing Address - Phone:715-808-0795
Mailing Address - Fax:715-808-0361
Practice Address - Street 1:1334 HOSFORD ST STE B
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-9230
Practice Address - Country:US
Practice Address - Phone:715-808-0795
Practice Address - Fax:715-808-0361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
WI1436-057103TC0700X, 103TC0700X
WI729-124106H00000X
MN1166106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN276P4BROtherGROUP NUMBER BCBS BNEVINS
WI374826056003OtherBCBS ANEVINS PIN
WI1710043070OtherNPI INDIVIDUAL ANEVINS
MN1982771317OtherNPI IND NUM ANGELA SILER
WI39172147012OtherBCBS GROUP NUMBER BEVINS
WI471547731E03OtherBCBS PIN BNEVINS
MN277P4NEOtherBCBS IND PROV NUM BNEVINS
WI39087700Medicaid
WI61-57474OtherUBH BRAD NEVINS
MN87G89NEOtherBCBS AUDREY NEVINS
MN96G67SIOtherBCBS IND NUM A SILER
MN936451035211OtherPREFERREDONE ANEVINS PIN
MN165875100Medicaid
WI62-70147OtherUBH AUDREYNEVINS
WI39692000Medicaid
MN110795OtherBNEVINS HEALTHPARTNERS GR
MN87G99BROtherGROUP NUM A NEVINS
MN96G77BROtherGROUP NUM ASILER
WI1710043070OtherNPI INDIVIDUAL ANEVINS