Provider Demographics
NPI:1922557800
Name:THRIVE THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:THRIVE THERAPY SERVICES LLC
Other - Org Name:THRIVE THERAPY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:EILER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-997-9411
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:WI
Mailing Address - Zip Code:53104-0488
Mailing Address - Country:US
Mailing Address - Phone:262-997-9411
Mailing Address - Fax:262-997-3844
Practice Address - Street 1:3200 SHERIDAN RD STE 104
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-1921
Practice Address - Country:US
Practice Address - Phone:262-997-9411
Practice Address - Fax:262-997-3844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5926-125251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1922557800OtherNPI (TYPE 2)
WI100032629Medicaid
WI100247525Medicaid