Provider Demographics
NPI:1720788300
Name:SUNRISE ABA OF WISCONSIN, LLC
Entity Type:Organization
Organization Name:SUNRISE ABA OF WISCONSIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:628-250-7500
Mailing Address - Street 1:505 SAN MARIN DR STE 100B
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-1309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6580 MONONA DR # 1173
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-4032
Practice Address - Country:US
Practice Address - Phone:628-250-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty