Provider Demographics
NPI:1881371540
Name:PREVAIL BEHAVIORAL HEALTH SC
Entity type:Organization
Organization Name:PREVAIL BEHAVIORAL HEALTH SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUSS
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:920-475-0333
Mailing Address - Street 1:15 PARK PL STE 200
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-8250
Mailing Address - Country:US
Mailing Address - Phone:920-475-0333
Mailing Address - Fax:
Practice Address - Street 1:15 PARK PL STE 200
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-8250
Practice Address - Country:US
Practice Address - Phone:920-475-0333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-03
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)