1336222769 NPI number — PSYCHOLOGY CLINIC INC.

Table of content: (NPI 1336222769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336222769 NPI number — PSYCHOLOGY CLINIC INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHOLOGY CLINIC INC.
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:
Provider Other Organization Name Type Code:
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:
1336222769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 N BLACKHAWK AVE STE 212
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53705-3357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-238-9991
Provider Business Mailing Address Fax Number:
608-238-1929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 N BLACKHAWK AVE STE 212
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53705-3357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-238-9991
Provider Business Practice Location Address Fax Number:
608-238-1929
Provider Enumeration Date:
10/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROETHE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PSYCHOLOGIST/CO-DIRECTOR
Authorized Official Telephone Number:
608-280-6486

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  1919 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 42161100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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