Provider Demographics
NPI:1053718890
Name:SPECTRUM BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:SPECTRUM BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARMODY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:920-784-2646
Mailing Address - Street 1:1496 BELLEVUE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-4205
Mailing Address - Country:US
Mailing Address - Phone:920-784-2644
Mailing Address - Fax:
Practice Address - Street 1:1496 BELLEVUE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4205
Practice Address - Country:US
Practice Address - Phone:920-784-2644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4151-125251S00000X
WI1826-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100043151Medicaid