1619156502 NPI number — CLINICAL PSYCHOLOGY ASSOCIATES, LLC

Table of content: (NPI 1619156502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619156502 NPI number — CLINICAL PSYCHOLOGY ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINICAL PSYCHOLOGY ASSOCIATES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLINICAL PSYCHOLOGY ASSOCIATES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619156502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
197 W CHESTNUT ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53105-1200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-763-9191
Provider Business Mailing Address Fax Number:
262-763-7767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
197 W CHESTNUT ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53105-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-763-9191
Provider Business Practice Location Address Fax Number:
262-763-7767
Provider Enumeration Date:
10/29/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
CLINIC DIRECTOR/OWNER
Authorized Official Telephone Number:
262-763-9191

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 1588 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 42171100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".